Journal of the Mississippi State Medical Association

dtALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

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HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

VOLUME XI

January- December, 1970

EDITOR

William M. Dabney, M.D.

ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

MANAGING EDITOR
Rowland B. Kennedy

EDITORIAL CONSULTANT
Betty M. Sadler

EDITORIAL ASSISTANT
Nola Gibson

PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.
Chairman

Frank L. Butler, Jr.. M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.
President

Arthur E. Brown, M.D.
President-elect

Raymond S. Martin, M.D.
Secretary-T reasurer

William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.
Vice Speaker

Rowland B. Kennedy
Executive Secretary

H. Cody Harrell

Assistant Executive Secretary

James F. McPherson, II
Executive Assistant

Mississippi State Medical Association
735 Riverside Drive
Jackson 39216

HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE

The Journal of the Mississippi State Medical Association
is owned and published by the Mississippi State Medical As-
sociation, founded December 15, 1856. Editorial, executive,
and business offices, 735 Riverside Drive, Jackson, Mississippi.
Office of publication, 1201-05 Bluff Street, Fulton, Mis-
souri. Copyright 1970, Mississippi State Medical Association.

Volume XI
Number 1

January 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL CONSULTANT
Betty M. Sadler

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
James L. Royals, M.D.

President

Paul B. Brumby, M.D.

President-elect
Walter H. Simmons, M.D.

Secretary-Treasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell

Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton.
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

ORIGINAL PAPERS

Practical Uses of Steroids
and Gonadotropins

in Obstetrics 1 Veasy C. B. Buttram,
Jr., M.D., Paige K.

Besch, Ph.D., and

L. Russell Malinak,

M. D.

Acute Illness Among

Returnees From Vietnam 8 Robert E. Blount, M.D.

Modern Concepts in
Treatment of Respiratory

Insufficiency 13 G. B. Shaw. M.D.

SPECIAL ARTICLE

Radiologic Seminar XCI:
Tracheoesophageal Fistula

18 Walter T. Colbert,
M.D.

EDITORIALS

Medicaid in Mississippi:

A Bare Bones Beginning 23 Million Dollar Shoestring

The Old Chit-Chat Gets

a Facelifting 25 Newsletter’s New Look

Mandatory Licensure for

Mississippi Nurses 25 Policy Decision

Jackson Chamber Honors

Health Care Team 26 Service Recognition

Our Environment Is at Stake 27 Pollution Dilemma

THIS MONTH

The President Speaking 22 Needed Now

Medical Organization 37 USM Student Health

Service Offers
Comprehensive Campus
Care Program

Copyright 1970, Mississippi State Medical Association

Convalescing ... but still a long way to go.
Anxiety can make it even longer.

Convalescence following medical or surgical procedures may be almost
endless to an anxious patient. And, indeed, anxiety with some patients
actually retards progress — for example, by inducing insomnia and reducing
cooperation.

As physicians have found during nearly 15 years of widespread use, Equanil
may be a beneficial part of aftercare. It helps relieve anxiety and tension,
thus often aiding your primary therapy.

Indications: For use in management of
anxiety and tension occurring alone or as
accompanying symptom complex to med-
ical and surgical disorders and pro-
cedures. Though not a hypnotic, fosters
normal sleep through antianxiety and
related muscle-relaxant properties.
Contraindications: History of sensitivity
to meprobamate.

Important Precautions: Carefully super-
vise dose and amounts prescribed, espe-
cially for patients prone to overdose
themselves. Excessive prolonged use has
been reported to result in dependence or
habituation in susceptible persons, as
alcoholics, ex-addicts, and other severe
psychoneurotics. After prolonged exces-
sive dosage, reduce dosage gradually to
avoid possibly severe withdrawal reac-
tions. Abrupt discontinuance of excessive
doses has sometimes resulted in epilepti-
form seizures.

Warn patients of possible reduced alcohol
tolerance, with resultant slowing of reac-
tion time and impairment of judgment and
coordination.

Reduce dose if drowsiness, ataxia or
visual disturbance occurs; if persistent,
patients should not operate vehicles or
dangerous machinery.

Side Effects include drowsiness, usually
transient; if persistent and associated with
ataxia, usually responds to dose reduc-
tion; occasionally concomitant CNS stim-
ulants (amphetamine, mephentermine
sulfate) are desirable. Allergic or idio-
syncratic reactions are rare, but such
reactions, sometimes severe, can develop
in patients receiving only 1 to 4 doses who
have had no previous contact with mepro-
bamate. Previous history of allergy may
or may not be related to incidence of
reactions. Mild reactions are charac-
terized by itchy urticarial or erythematous
maculopapular rash, generalized or con-
fined to groin. Acute nonthrombocyto-
penic purpura with cutaneous petechiae,
ecchymoses, peripheral edema and fever
have been reported. One fatal case of
bullous dermatitis following intermittent
use of meprobamate with prednisolone
has been reported. If allergic reaction
occurs, meprobamate should be stopped
and not reinstituted. Severe reactions,

observed very rarely, include angioneu-
rotic edema, bronchial spasms, fever,
fainting spells, hypotensive crises (1 fatal
case), anaphylaxis, stomatitis and proc-
titis (1 case) and hyperthermia. Treat
symptomatically as with epinephrine, anti-
histamine and possibly hydrocortisone.
Aplastic anemia (1 fatal case), thrombo-
cytopenic purpura, agranulocytosis and
hemolytic anemia have occurred rarely,
almost always in presence of known toxic
agents. A few cases of leukopenia, usually
transient, have been reported on con-
tinuous administration.

Meprobamate may sometimes precipitate
grand mal attacks in patients susceptible
to both grand and petit mal. Extremely
large doses can produce rhythmic fast
activity in the cortical pattern. Impairment
of accommodation and visual acuity has
been reported rarely. After excessive
dosage for weeks or months, withdraw
gradually (1 or 2 weeks) to avoid recur-
rence of pretreatment symptoms (insom-
nia, severe anxiety, anorexia). Abrupt
discontinuance of excessive doses has
sometimes resulted in vomiting, ataxia,
tremors, muscle twitching and epilepti-
form seizures. Prescribe very cautiously
and in small amounts for patients with
suicidal tendencies. Suicidal attempts
have resulted in coma, shock, vasomotor
and respiratory collapse and anuria. Ex-
cessive doses have resulted in prompt
sleep; reduction of blood pressure, pulse
and respiratory rates to basal levels; and
occasionally hyperventilation. Treat with
immediate gastric lavage and appropriate
symptomatic therapy. (CNS stimulants
and pressor amines as indicated.) Doses
above 2400 mg. /day are not recom-
mended.

Composition: Tablets, 200 mg. and 400
mg. meprobamate. Coated Tablets,
WYSEALS® EQUANIL (meprobamate) 400
mg. (All tablets also available in
REDIPAK® [strip pack], Wyeth.) Contin-
uous-Release Capsules, EQUANIL L-A
(meprobamate) 400 mg.

EQUANIL

(meprobamate)

Wyeth Laboratories Philadelphia, Pa.

Photo professionally posed.

January 1970

? Doctor:

sissippi Hospital and Medical Service (Blue Cross-Blue Shield)
been named fiscal administrator for Medicaid. Commission made
iuncement in pre-Christmas news conference, and estimates are
t program will cost 6 per cent of $33*4 million budget or about
nillion per year to administer.

Selection of fiscal administrator was narrowed when
insurance companies pulled out of bidding! The Blue
plan was the only bidder for the gargantuan task of
program administration, paying physicians, hospitals,
nursing homes, and health agencies.

fsident Nixon conducted closed-door conference with AMA leader-
p delegation made up of President Dorman and group of Trustees,
ee subjects were discussed: Medical manpower shortages , care

its, and services to the poor. AMA has initiated positive pro-
ms to get manpower up, costs held, and care delivery to poor.

st recommendations from the McNerney Medicaid Task Force will
r heavily upon delivery system and alter federal pay policy,
emey wants 5 per cent of Medicare budget or $130 million to
toward paying for medical services on a fee-for-time basis
for group practice payments. Plan, however, does not exclude
-for-service under traditional delivery patterns - yet.

yersity Medical Center growth may be impaired if construction
ds are not provided within next year! Facilities are squeez-
with record enrollment of 778 students in all programs. Class
*73 has 90 beginning medical students, and degree nurse enroll-
.t is 142. Various allied programs account for remainder, and
student is pursuing combination M.D.-Ph.D. degree.

[A headquarters office has a new telephone number made necessary
building expansion. Make a note of 354-4533 with Area Code 66l.
Iding addition is virtually complete and scheduled for occupancy
next two weeks. Watch for announcement of February open house.

Rowland B. Kennedy
Executive Secretary

THE JOURNAL FOR JANUARY 1970

1 0

Surgeons Plan
Meet in St. Paul

The American College of Surgeons will hold
the second of three 1970 Sectional Meetings in
St. Paul, Minn., Feb. 16-18. Some 550 surgeons
are expected to attend this intensive three-day
program, open to all doctors of medicine. This
is the first ACS meeting in St. Paul since 1957.
Headquarters hotel is the St. Paul Hilton.

Dr. Frederick M. Owens, Jr., clinical as-
sociate professor of surgery, University of Min-
nesota Medical School, and his local advisory
committee on arrangements, have selected a dis-
tinguished faculty to present “How-I-Do-It” clin-
ics, panel discussions, scientific papers, symposia,
and medical films in general surgery and the spe-
cialties of otorhinolaryngology, thoracic surgery
and urology.

Subjects to be covered include vascular sur-
gery, rhinoplasty and septoplasty, mediastinos-
copy, perforation of the esophagus, cardiac in-
juries, emergency treatment of head injuries in
Viet Nam, arterial surgery for renal disease, pros-
tatic carcinoma, Wilms’ tumor, carcinoma of the
breast and transportation of the injured patient.

Assisting Chairman Owens are these Minne-
sota Fellows of the College: general surgeons
Lyle J. Hay; Armond J. Kremen; John F. Perry,
Jr.,; Edward W. Humphrey: Lyle A. Tongen;
F. Henry Ellis, Jr.; Claude R. Hitchcock. Spe-
cialty representatives are Joseph H. Pratt, gyne-
cology-obstetrics; Hendrik J. Svien, neurosur-
gery; Malcolm A. McCannel, ophthalmology;
Jerome A. Hilger, otorhinolaryngology; Donald
R. Lannin, orthopedics; John B. Erich, plastic;
Loren E. Nelson, proctology; Josiah Fuller, tho-
racic, and Edward J. Richardson, urology.

Hotel reservation forms may be obtained by
writing directly to the St. Paul Hilton, St. Paul,
Minn. 55101, or Mr. T. E. McGinnis, Amer-
ican College of Surgeons, 55 East Erie Street,
Chicago, 111. 60611. No registration fee is charged
Fellows of the College, members of the Candi-
date Group, residents or interns who present let-
ters of identification signed by chiefs of surgery
or the hospital administrator. Non-Fellows pay
$15.00. Doctors in the Federal Services pay
$7.50.

Dr. Robert J. Kamish, Chicago, assistant di-
rector, is in charge of scientific sessions for all
Sectional Meetings. Dr. C. Rollins Hanlon, Chi-
cago, is director of the College. Dr. Joel W.
Baker, Seattle, is president.

HIGHLAND HOSPITAL

Asheville, North Carolina

FOUNDED 1904

A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY

Accredited by the Joint Commission on Accreditation and Certified for Medicare

Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho-
therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser-
vice work with families, family therapy and an extensive and well organized activities program, including oc-
cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The
treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may
be realized.

High school facilities for a limited number of appropriate patients are now available on grounds. The School
Program is fully integrated into the hospital treatment program and is accredited through the Asheville School
System.

Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.

Brochures and information on financial arrangements available
Contact: Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions

or

Charles W. Neville, Jr., M.D.

Assistant Professor of Psychiatry and Medical Director
Area Code 704-254-3201

MISSISSIPPI STATE MEDICAL ASSOCIATION

CHP Study
Is Published

The goals, priorities and problem areas of com-
prehensive health planning are reviewed in a new
document issued by the Health Insurance Council.

Entitled “Community Health Action-Planning
— Problems and Potentials,” the 22-page publica-
tion is designed as an introductory guide to plan-
ning for business and professional leadership in-
volved in state and community health activities.

Included is information on the history of health
planning, key provisions of planning legislation,
suggested organization and relationship of health
agencies within a state, criteria for effective area-
wide planning agencies, priority actions to be
taken by agencies, and barriers that may be en-
countered.

In a concluding summary, the author, David
Robbins, Controller and Director of Statistics,
Health Insurance Association of America, urges a
concerted effort by business executives to help

1 i

solve the problems of health facilities, services,
manpower and environment.

A special report issued in conjunction with the
booklet reviews the progress of the Health Insur-
ance Council Program for Community Health Ac-
tion-Planning (HiCHAP), noting that “every ini-
tial goal of the program has been filled.”

The Council, in its report, said that insurance
companies representatives serving as HiCHAP co-
ordinators are active in 45 states. Of the Gover-
nor’s Advisory Councils now formed in 46 states,
the District of Columbia, and Puerto Rico under
the Partnership for Health law, insurance compa-
ny executives have been appointed to 35 of these
councils, and in eight states serve as chairman.

It further reports that insurance representatives
are on the boards and committees of over half of
the more than 80 areawide health planning agen-
cies funded to date by the federal government.

Copies of the health planning document and
the HiCHAP progress report may be obtained
without charge from the Health Insurance Coun-
cil, 750 Third Avenue, New York 10017.

Announcing the Thirty -Third Annual Meeting nf
THE MEW ORLEANS GRADUATE MEDIEAL ASSEMRLY

Conference Headquarters — The Roosevelt Hotel- — March 2, 3, 4, 5, 1970

GUEST SPEAKERS

John J. Bonica, M.D.. Seattle, Wash.
Anesthesiology

John R. Hill, M.D., Rochester, Minn.

Colon and Rectal Surgery
Walter B. Shelley, M.D., Philadelphia, Pa.
Dermatology

H. M. Pollard, M.D., Ann Arbor, Mich.

Gastroenterology
Walter Lane, M.D., Tampa, Fla.

General Practice

Henry Clay Frick, II, M.D., New York, N.Y.
Gynecology

William H. Crosby, Jr., M.D., Boston, Mass.
Internal Medicine

Thomas L. Petty, M.D., Denver, Colo.
Internal Medicine

David N. Danforth, M.D., Chicago, 111.
Obstetrics

Jack A. Dillahunt, M.D., Albuquerque, N.M.
Ophthalmology

John J. Niebauer, M.D., San Francisco, Calif.
Orthopedic Surgery

William K. Wright, M.D., Houston, Tex.
Otolaryngology

Omer E. Hagebusch, M.D., St. Louis. Mo.
Pathology

Chester M. Edelmann, Jr., M.D., Bronx, N.Y.
Pediatrics

Howard P. Rome, M.D., Rochester, Minn.
Psychiatry

Wendell P. Stampfli, M.D.. Denver, Colo.
Radiology

Joel W. Baker, M.D., Seattle, Wash.

Surgery

Edwin J. Wylie, M.D., San Francisco, Calif.
Surgery

Ralph A. Straffon, M.D., Cleveland, Ohio
Urology

Lectures, symposia, clinicopathologic conference, round-table luncheons, medical motion pictures, technical exhibits,
and entertainment for visiting wives. (All-inclusive registration fee — S35.00.)

This program is acceptable for twenty-two (22) prescribed hours and nine (9) elective hours by the American Acad-
emy of General Practice.

For information concerning the Assembly meeting write Secretary,

The Newr Orleans Graduate Medical Assembly, Room 1538,

1430 Tulane Avenue, New Orleans, Louisiana 70112.

for the debilitated
geriatric patient

TABLETS

high potency B-complex and C
for nutritional support

AVAILABLE ONLY ON Rx
contains water-soluble vitamins only
b.i.d. dosage
good patient acceptance
no odor, and virtually no aftertaste

Each Berocca Tablet contains:

Thiamine mononitrate 15 mg

Riboflavin 15 mg

Pyridoxine HCI 5 mg

Niacinamide 100 mg

Calcium pantothenate 20 mg

Cyanocobalamin 5 meg

Folic acid 0.5 mg

Ascorbic acid 500 mg

Usual dosage is one tablet b.i.d.

Indications: Nutritional supplementation in conditions in
which water-soluble vitamins are required prophylactically
or therapeutically.

Warning: Not intended for treatment of pernicious anemia
or other primary or secondary anemias. Neurologic involve-
ment may develop or progress, despite temporary remission
of anemia, in patients with pernicious anemia who receive
more than 0.1 mg of folic acid per day and who are in-
adequately treated with vitamin B12.

Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

Roche

LABORATORIES

Division ol Hoffmann-La Roche Inc.
Nutley. New Jersey 07110

1 Pot Policy Chicago - AMA's new policy position on mari-

hs Hard tine juana minces no words in characterizing can-

nabis as "a dangerous drug. ..and a psycho-
■Lve substance which can have a marked deleterious effect...”
Icy says that sale and possession of marijuana should not be
^alized, pointing out that if potency were legally controlled,
ice would predictably be an illicit market.

Makers Hit New York - The Tobacco Institute, trade as-

ismoking Spots sociation for cigarette manufacturers, took

full page ads in newspapers to protest what
.called "untruthful and misleading statements” by American Can-
: Society and American Heart Association in forced-free-time
commercials discouraging smoking. TI said that such commercials
uuld be stopped. FCC requires networks to give time to offset
bes pitches equating smoking with outdoors and the good life.

itists Get Blow Washington - After extensive study, HEW has
"m HEW, APHA reported to the Congress that chiropractic

is quackery and that payment for spine punchers*
i vices should not be made in Medicare program. American Public
s.lth Association followed up by concurring and asking that no
ament be made to chiropractors under Title XIX Medicaid. Mis-
. sippi program cannot pay cultists under existing law.

sil Dogpatch Gets Dogpatch. Ark. - Sen. J. William Fullbright
:leral Handout (D. ,Ark. ) has accomplished what A1 Capp*s

mythical Sen. Jack S. (Good Ole Jack S. ) Phog-
;md has never been able to do in the popular comic strip, "Li'l
ler”: He got $120,000 in sure *nuff federal money for Dogpatch,

c. , a private amusement park. Money will provide hillbilly Dis-
fland water and sewerage services under public health aegis.

V Disposal Poses Ft. De trick, Md. - The U.S. Chemical and Bio-
alth Problems logical Warfare Center has the problem of carry-

ing out President Nixon* s edict to dispose of
3 nation* s stockpile of CBW weapons. Although top secret, deadly
senal is known to contain potent strains of anthrax, encephalitis,
ague, Q fever, Chikungunya fever, and a host of fatal bugs. CBW
LI henceforth be confined to defensive research and vaccines.

THE JOURNAL FOR JANUARY 1970

1 4

equivalent to

Erythromycin Estolate

Each 5 cc. contain
erythromycin estolate
equivalent to 250 mg.
erythromycin base.

When mixed as directed,
each 5 cc. will contain erythromycin
estolate equivalent to 125 mg.
erythromycin base.

Hr When mixed as
f directed, each cc.

will contain
erythromycin estolate
equivalent to 100 mg.
erythromycin base.

mMmmmmmm.

Each tablet contain

Each 5 cc. contain
erythromycin estolate
equivalent to 125 mg.
erythromycin base.

The many
forms
of Ilosone

Each Pulvule® contains
erythromycin estolate
equivalent to 125 mg.
erythromycin base.

Additional information
available upon request.

Eli Lilly and Company
Indianapolis, Indiana 46206

Each Pulvule contains
erythromycin estolate
equivalent to 250 mg.
erythromycin base.

900761

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

January 1970, Vol. XI, No. 1

Practical Uses of Steroids and
Gonadotropins in Obstetrics

and Gynecology

VEASY C. B. BUTTRAM, JR., M.D., PAIGE K. BESCH, Ph.D., and

L. RUSSELL MALINAK, M.D.

Houston, Texas

The obstetrician and gynecologist frequent-
ly encounters a patient who exhibits signs and
symptoms which might indicate an endocrine
abnormality. Before undertaking a workup, the
physician should know just what tests are avail-
able to him, what tests might be of benefit both
in the diagnosis and treatment, the time and ex-
penses involved, and how to interpret the labo-
ratory results that he may obtain. The purpose
of this paper is to discuss several steroid and
gonadotropin determinations that are available
to practicing physicians and place emphasis par-
ticularly upon their practical use.

Estrogens are phenolic steroids that are se-
creted by the ovaries, adrenal glands, testicles
and the fetal-placental unit. At the present time,
there are known to be at least 20-25 metabolites
in the urine which can be considered estrogens.
The metabolites that are most important are
known as Ei (estrone), E2 (estridiol) and E3
(estriol). Et and E2 are primarily secreted by the

From the Department of Obstetrics and Gynecology,
Baylor University College of Medicine.

Read before the Section on Obstetrics and Gynecology,
101st Annual Session, Mississippi State Medical As-
sociation, Biloxi. May 13, 1969.

ovaries in the non-pregnant female. A small
amount of estrone and estridiol can be secreted
by the adrenal gland. Estriol in the non-gravid
female is produced primarily in the liver from
metabolism of estrone and estridiol; in the gravid
female, the major portion of estriol is produced
in the fetal-placental unit.

The availability and benefit of tests, the
time and expenses involved and the inter-
pretation of laboratory results are things a
physician must know before undertaking a
workup of a patient who appears to have
endocrine abnormality. Several steroid and
gonadotropin determinations available to
practicing physicians are discussed with par-
ticular emphasis placed upon their practical
use. Diagnostic methods expected to be
available in the near future are also con-
sidered.

Before an estrogen determination is ordered,
it should be emphasized that there are interfer-
ing agents which alter the estrogen values ob-
tained from urine. These consist of hormones

JANUARY 1970

1

STEROID USAGE / Buttram et al

which inhibit hypothalamic-pituitary-ovarian func-
tion, i.e., contraceptives. The cost of a total uri-
nary estrogen determination ranges from $15-$30
and the time involved varies from 4-24 hours.
Fractionated estrogens on the other hand costs
approximately $30-$50, and the time required
for such a determination is seven days.

ESTROGEN PEAK

In the pre-menopausal female, estrogen values
range from 5-25 /ngm per 24 hours. It is well
known that the estrogen value is greatest just
prior to ovulation. (See Chart I.) LH release
and subsequent ovulation is apparently depen-
dent on this peak. There is also a peak of estrogen
in the mid-portion of the luteal phase of the cycle.
Why females have this second surge of estrogen
is not known. It has been theorized that it is due
to the release of estrogen from other follicles
that were stimulated by FSH in the pre-ovula-
tory and post-ovulatory phase of the menstrual

cycle which did not mature to the stage needed
for ovulation. These follicles persist during the
luteal phase of the menstrual cycle, and it is con-
ceivable that they produce estrogen at that time.

The initial peak of estrogen is secreted by the
follicle which has been brought to maturity un-
der FSH stimulation and subsequently ovulates
following LH release. Thus, during the earlier
portion of the menstrual cycle, the estrogen value
is at its lowest level and may range from 5-10
^gm for 24 hours (Table I). The level of estro-
gen during the mid-portion of the menstrual
cycle prior to ovulation and during mid-luteal
phase may approach the 25 ^gm peak. The nor-
mal value of estrogen in a post-menopausal
woman varies from 5-10 ^gm per hour. The
major portion of this estrogen comes from the
adrenal glands.

The proper clinical use of estrogen determi-
nations in the evaluation and treatment of endo-
crine abnormalities is variable. In the normal
menstruating female an estrogen determination
is seldom of benefit in the diagnosis or treatment

-13-11-9-7-5-3-1 1 3 5 7 91113 15

DAY OF CYCLE

Chart I. The variation of the three major urinary estrogens during the menstrual cycle.

2

JOURNAL MSMA

TABLE I

SOME NORMAL URINARY STEROID VALUES IN THE WOMAN

Steroid Pre-Ovulatory Post-Ovulatory Post-Menopausal Pregnancy

Total Estrogen (/i gm) 5-10 5-25 5-10 8-35 mg*

Pregnanediol (mg) <0.2 0.8-3. 5 <0.5 5-30*

17-Ketosteroids (mg) 5-8 5-15 3-8 5-20

17-Hydroxycorticoids (mg) 3-5 3-8 2-5 3-8

Testosterone (/x gm ) 0-10 10-20 10-30 ?

HCG — — — 800-100,000 IU*

* These values vary with gestational age.

of an endocrine abnormality. We feel that a wom-
an who is having normal menstrual cycles will
have an estrogen level that is within the 5-25
/xgm normal range. Therefore, an estrogen de-
termination would be of little practical value to
the physician in this patient. In the amenorrheic
female, an estrogen determination may be of
some benefit (Table II). Further discussion of
the practical use of estrogen will follow the intro-
duction of the gonadotropins.

GONADOTROPIN VALUES

The pituitary gland is the only organ known
to produce human pituitary gonadotropins. The
interfering agents which alter the urinary values
are estrogens, androgens, and progestins. Some
of the frequently used tranquilizers, sedatives,
and narcotics also interfere; they suppress the
hypothalamus or pituitary gland. The cost ranges
from $20-$35, and the time required for this
particular determination is approximately two
weeks in most laboratories. This is one of the
crudest laboratory determinations. Normal values
in the pre-menopausal woman range between
6-48 m.u. per 24 hours and in the post-meno-
pausal female, between 48-192 m.u. per 24
hours. The clinical usefulness is hampered by the

TABLE II

ESTROGENS MAY BE OF VALUE IN
THESE DISORDERS

1. Hypothalamic amenorrhea

2. Amenorrhea-galactorrhea syndrome

3. Hypopituitarism

4. Ovarian agenesis or dysgenesis

5. Premature ovarian failure

6. Congenital absences of the vagina

7. Gonadotropin therapy

8. Estrogen secreting tumors of the ovary

9. Gynecomastia in the male

fact that the determination is so crude. Only
values which are extremely high or repeatedly
low are of benefit to the practicing physician.

In the normal menstruating female, a total
pituitary gonadotropin level is of no benefit in
evaluating a problem. If she is menstruating,
even if infrequently, she is producing enough
FSH to stimulate the follicles to produce estro-
gen. The urinary gonadotropic (HPG) value
would possibly be low but still within normal
range. Only in the completely amenorrheic fe-
male is the total pituitary gonadotropin determi-
nation of any value to the physician. In the
menopausal woman or one with ovarian failure,
a tremendous increase in the trophic hormones
urinary level occurs. In hypothalamic or pitui-
tary pathology, low values for the trophic hor-
mones are expected; this is frequently not the
case, however. This is possibly due to the wide
range of normal for the test and the low value
that is reported to be within normal limits.

NORMAL VALUES

In the hypothalamic amenorrheic syndrome,
the amenorrhea-galactorrhea syndrome, or in hy-
popituitarism, estrogen values are usually in the
low normal range. This also is apparently due to
the wide range of normal values for urinary
estrogen and the fact that the adrenal glands
can produce enough estrogen to give a value of
5 pgm or more. Therefore, the culdoscopic find-
ing of unstimulated ovaries may be of more
practical value than an estrogen or gonadotropin
determination. These estrogen deficient patients
generally respond poorly to Clomid. An estrogen
determination might give some prognostic infor-
mation, as we feel that those individuals who
have high normal estrogen values respond much
more favorably.

JANUARY 1970

3

STEROID USAGE / Buttram et al

Patients with ovarian agenesis or dysgenesis
or premature ovarian failure generally have a
low normal or low estrogen level and a high
gonadotropin titer. Evaluation of the vaginal mu-
cosa for estrogen effect is as beneficial as an
estrogen determination in the above-mentioned
problem and is less expensive.

In those rare cases of congenital absence of
the vagina, where a vaginal smear cannot be ob-
tained, an estrogen determination may be of some
benefit to the physician. A high normal estrogen
level would indicate that ovaries are present. A
urinary cytogram for estrogen effect may also be
of value.

GONADOTROPIN THERAPY

In the recent past, gonadotropin therapy has
been used with qualified success in infertile pa-
tients with low gonadotropic hormone release.
At the present time, it is difficult to know just
how much FSH to administer and the amount
required varies considerably in each individual.
Estrogen values during and following gonadotro-
pin therapy have been of some benefit. During
gonadotropin therapy, the estrogen value should
rise. Evaluation of this estrogen output is bene-
ficial in evaluating further FSH need. However,
because estrogen determinations are time consum-
ing and costly; their use in patients receiving
gonadotropin therapy has been less than ideal.

Occasionally, an estrogen secreting ovarian
tumor may be diagnosed by estrogen determina-
tions. Generally, this is not the case. Most pa-

tients with ovarian tumors that secrete estrogen
will have a palpable adnexal mass. Following ex-
cision of a functioning ovarian tumor, subsequent
estrogen determinations might indicate recurrence
or metastatic disease. Likewise, in male patients
with gynecomastia, an estrogen determination
may be of some benefit in both diagnosis and
treatment.

PRACTICAL USES

The greatest practical use of estrogen determina-
tions is in the pregnant female. Placental insuffi-
ciency may be associated with postmaturity, dysma-
turity, diabetes, and toxemia of pregnancy. The
estrogen values in pregnancy are increased 1,000
fold over those in the non-pregnant female. Re-
cent investigations indicate that urinary estrogen
levels in the third trimester of pregnancy are in-
dicative of feto-placental well being. It is impor-
tant that frequent determinations be obtained;
delivery of the infant should be considered when
an estrogen value drops 50 per cent or more.
The total estrogen value is not as important as is
a decrease which is noted on serial determina-
tions. In some cases, fetal death in utero may be
diagnosed by a low estrogen level. Also, it has
been recommended by some authors that estro-
gen values accurately reflect fetal size and should
be performed on any patient prior to elective
repeat cesarean section.

Progesterone is known to be produced in the
ovary, adrenal, testes, and placenta. There are
more than 20 compounds in the urine which can
be considered progesterone metabolites; of these,
pregnanediol (PL>) is the most important. (See

Chart 11. Urinary pregnanediol excretion throughout the normal cycle.

4

JOURNAL MSM A

Chart II.) Any agent which contains estrogen,
progesterone or androgen can suppress the hy-
pothalamus and the pituitary gland and thus in-
terfere with the pregnanediol determination. The
cost of this test is approximately $15 and the
time required is two days (Table II). The non-
gravid female excretes 0. 5-0.9 mg pregnanediol
each 24 hours in the follicular phase of the men-
strual cycle and 0.9-3. 5 mg each 24 hours in the
luteal phase. In the pregnant female, the preg-
nanediol values increase approximately 2.75
mg/24 hours each gestational month. The normal
day-to-day variation in excretion is considerable;
thus the test is of little value.

There is no practical value of pregnanediol
determinations in pregnancy. It has been felt
that the P2 value was indicative of fetal-placental
well being. Recent investigations have virtually
disproved this hypothesis. In the menstruating
female, the pregnanediol value may be of some
benefit for detection of ovulation, but other
tests such as basal body temperatures or endo-
metrial biopsies are as enlightening and less ex-
pensive. In the amenorrheic female, P> values
are never of benefit, simply because the amenor-
rheic patient rarely ovulates.

STEROID METABOLISM

Urinary 1 7-hydroxycorticoids are produced
only from the metabolism of steroids produced in
the adrenal glands. There are many compounds
in the urine which react chemically as 1 7-hy-
droxycorticoids. The interfering agents are iodides,
paraldehyde, chloral hydrate, sulphur drugs,
chlorophenothiazine, spironolactones, Furadantin,
quinine, colchicine, Darvon, bilirubin, glucose,
coffee, spinach, and others. Stress may cause an
increase in 1 7-hydroxycorticoids. When the pa-
tient enters the hospital for endocrine evaluation,
she is generally anxious; thus a temporary in-
crease in 1 7-hydroxycorticoids may occur. The
cost of this procedure is approximately $15, and
the time involved is usually three days. The nor-
mal values vary with each laboratory. Generally,
5-10 mg. per 24 hours is considered normal for
a male and 2-8 mg. per 24 hours for a female.

The clinical use of 1 7-hydroxycorticoids is re-
lated to its value as a screening procedure for
adrenal disorders. In Cushing syndrome in which
an over-production of cortisol occurs 1 7-hydroxy-
corticoids are increased. In congenital and ac-
quired adrenal hyperplasia, the 1 7-hydroxy-
corticoids are normal or low normal. These pa-
tients have compensated for their enzymatic de-

fect and thereby produce enough hydrocortisone
to survive. In Addison’s disease and panhypo-
pituitarism, low normal or slightly subnormal
levels are found. These values are only sugges-
tive, not diagnostic. Also, Addison’s disease and
panhypopituitarism cannot be differentiated by a
1 7-hydroxycorticoid value alone.

ORIGIN OF 17-KETOSTEROIDS

Origins of 17-ketosteroids are the ovaries,
adrenal glands, testicles and placenta. There are
a number of 17-ketosteroids in the urine but only
seven are of importance. Among the interfering
agents are such substances as ascorbic acid, Dori-
den, morphine, mephrobamate. Stress may also give
false high values. The cost ranges from $7.50-$ 15
and the time required is around two days. Most
procedures used to detect urinary 17-ketosteroids
are very crude, and at best the determination is a
measurement of weak androgens produced in
the body. Twenty to 40 per cent of the 17-
ketosteroid values may be non-specific urinary
chromogens. For example, of 12 mg/24 hours
for a female, 2-4 mg. of this determination may
be interfering urinary chromogens that are not
1 7-ketosteroids. The normal values vary with the
laboratory; the male range is 8-20 mg. per 24
hours, and that of the female is 5-15 mg. per 24
hours.

As with the 1 7-hydroxycorticoids, 17-ketoster-
oids are used primarily as a screening procedure
for adrenal pathology. When an increase in 17-
ketosteroids is obtained, it should be assumed
that the problem lies in the adrenal gland until
proven otherwise. Secretion of 17-ketosteroid in-
creases in adrenal tumors, Cushing syndrome,
congenital adrenal hyperplasia and possibly in
acquired adrenal hyperplasia and borderline
adrenal dysfunction. In Addison’s disease and
panhypopituitarism low normal to sub-normal
values of 17-ketosteroids are present. Although
ovarian pathology may cause an increase in 17-
ketosteroids, this is generally not the case. Ele-
vated 17-ketosteroid values are occasionally as-
sociated with adrenal rest tumors of the ovaries
or arrhenoblastomas. A discussion of 17-keto-
steroid values in patients with enzymatic pathol-
ogy of the ovaries and/or the adrenal glands will
appear later in this paper.

Testosterone can be produced in the ovaries,
testicles and probably to a small degree by the
adrenals. Precursors of testosterone are produced
abundantly by each of these glands. Conver-
sion of these precursors to testosterone may

JANUARY 1970

5

STEROID USAGE / Buttram et al

take place in the liver and other peripheral
sites. The interfering agents are corticoids, estro-
gens, progestins, and androgens, as these may al-
ter the biosynthesis of the secreting endocrine
gland. The cost varies from $35-$55, and the time
required is approximately two weeks. Testoster-
one is not a 1 7-ketosteroid. It is present both in
the urine and the plasma. Androstenedione is
a 1 7-ketosteroid which is found only in the plas-
ma. Dehydroepiandrosterone (DHEA) is the
most androgenic 1 7-ketosteroid found in the
urine. If testosterone is given an androgenicity
value, androstenefione is one-tenth and DHEA
is one-thirtieth of that value. The metabolism of
these compounds are shown in Chart III. Urinary
1 7-ketosteroids are measurements of the weakest
androgens produced in the body and do not re-
flect unmetabolized androstenedione or testoster-
one. The normal values for urinary testosterone
in the male are 30-200 ^gm for 24 hours and 0-20
gm for 24 hours in the female. In the plasma,
the value is approximately 0.68 g gm and 0.10 /xgm
respectively. In the normally menstruating fe-
male, testosterone levels vary throughout the
menstrual cycle; the peak of testosterone is
around the time of ovulation, apparently stimu-
lated by the LH peak.

Metabolism of Some Endogenously Produced Androgens

D ehyd ro epiandro s te ro ne

1 7-ketosteroids. Occasionally, both testosterone
and the 1 7-ketosteroids are increased. Using these
generalizations, a differentiation between primary
ovarian and primary adrenal enzymatic pathol-
ogy can usually be made. When an enzymatic
deficiency in either gland is so mild that it cannot
be detected by measurement of testosterone or
1 7-ketosteroids, a diagnostic dilemma is present.
A similar diagnostic problem arises when enzy-
matic deficiencies are present in both endocrine
glands.

URINARY TESTOSTERONE

Androgen secreting ovarian tumors, such as
arrhenoblastoma and hilus cell tumors, are gen-
erally associated with an increase in urinary tes-
tosterone. These particular tumors may cause no
increase in 1 7-ketosteroids. In contradistinction,
adrenal tumors usually secrete a large amount of
1 7-ketosteroids and little testosterone. Plasma
testosterone values have not as yet been well cor-
related with disease processes.

Human chorionic gonadotropin is produced by
the placenta. There are multiple methods of de-
tection of this trophic hormone. The hemaggluti-
nation tests have a sensitivity as low as 800-1000
IU of HCG. The time required is generally 2-4
hours and the approximate cost is $5. The latex
agglutination tests have a sensitivity as low as
2000 IU of HCG and the time required is 2-3
minutes; the cost is around $3. The complement
fixation test is rarely used today. The radioim-
munoassay technique, which is relatively new, is
very specific and sensitive, and can detect HCG
values as low as 0.06 HCG per ml. of serum. The
bioassay techniques used in the past were fairly
specific and quantitative for HCG but due to the
crudeness and the methodology involved, these
techniques are currently seldom used.

LH AND HCG DETERMINATIONS

Chart 111. Metabolism of some endogenously pro-
duced androgens.

Testosterone determinations are useful in dif-
ferentiating ovarian from adrenal pathology.
When a major enzymatic deficiency exists in the
ovary, excess androgen production occurs gener-
ally in the form of elevated testosterone. Occa-
sionally, both testosterone and 1 7-ketosteroids
are elevated. When a major enzymatic deficiency
exists in the adrenal gland, excess androgen pro-
duction occurs generally in the form of elevated

Lutenizing hormone (LH) and human chori-
onic gonadotropin (HCG) crossreact immuno-
logically. Thus, 10 units of LH plus 10 units of
HCG react immunologically as 20 units. In the
normally menstruating female, the peak of LH
is around mid-cycle and ranges from 200-300
IU HCG (Chart IV). In the post-menopausal
female, the LH value may be 600 IU HCG. If
a sensitive immunological test for HCG is used, a
positive pregnancy test in a post-menopausal
female may occur when the LH titer approxi-
mates 600-800 IU HCG. HCG titers are de-
tectable on the 24th day of pregnancy; by day

6

JOURNAL MSMA

MEAN URINARY EXCRETION OF FSH & LH ACTIVITY ARRANGED ACCORDING
TO THE DEVIATIONS FROM THE TIME OF MAXIMAL LH EXCRETION
IN EACH CYCLE (64 NORMAL CYCLES)

DAYS

Composition pattern of FSH and LH excretion. Vertical lines represent the standard error.
(From Stevens, 1966.)

Chart IV. Pattern of LH & FSH during the normal cycle.

30, there is a 100-fold increase, and by day 42,
the value is increased some 3000 fold. The peak
of HCG is noted around the 50th-70th day of
gestation.

The best clinical use of HCG determinations
is in diagnosis of pregnancy. If a sensitive tech-
nique is used properly, a positive pregnancy test
occurs by day 30 of the menstrual cycle or 16
days after conception. Most physicians delay
this determination until day 42 because some
women ovulate later than day 14.

This test is useful in the diagnosis of hydatidi-
form mole and choriocarcinoma; it must be
stressed, however, that very high levels of HCG
may occur in normal pregnancy during the third
month. The post-treatment care of the patient
with trophoblastic disease is enhanced by very
sensitive techniques for HCG determinations.

In the near future, the obstetrician and gyne-

cologist will have several new methods for ster-
oid and gonadotropin determination which will
aid both in diagnosis and treatment of endocrine
abnormalities. The competitive protein binding
technique for estrogen, progesterone and testos-
terone appears to be a very rapid, accurate and
sensitive method for detection of these steroids,
although it is still in the early stages of develop-
ment. The radioimmunoassay for FSH and LH
and other trophic hormones is also in its infancy.
This technique is complex but holds a lot of
promise for all physicians and individuals inter-
ested in the field of reproductive physiology'.
Production and secretion rates are complicated
and have not to date been useful in clinical ob-
stetrics and gynecology. Conversion studies of
steroids are also complex, but they appear prom-
ising for future practicing physicians. ***

5353 Dora Street (77005)

JANUARY 1970

7

Acute Illness Among Returnees

From Vietnam

ROBERT E. BLOUNT, M.D.

Jackson, Mississippi

It is estimated that, during 1970 more than
6,000 Mississippians will be returning to the
United States after completing a 12-month tour
of duty in Vietnam. Traveling by jet, these troops
may arrive home during the incubation period of
a number of tropical diseases.

Those who have engaged in combat in the
Central Highlands of South Vietnam probably have
been exposed to virulent strains of Plasmodium
falciparum malaria. These troops have been tak-
ing a tablet containing 300 mg. Chloroquine
(base) and 45 mg. primaquine (base) once
weekly as chemoprophylaxis. Some are receiving
a daily dosage of 25 mg. of diaminodiphenyl-
sulfone (Dapsone) as a third chemosuppres-
sive agent. On being rotated from Vietnam, each
individual is issued a supply of the chloroquine-
primaquine tablets with instructions to take one
each week for eight weeks. He is warned not to
use these combined tablets for the therapy of
any clinical illness because of the hemolytic po-
tential of the larger dosage of primaquine in-
volved. Most returning troops are also given a
supply of Dapsone tablets and instructed to take
one daily (in addition to the weekly doses of
chloroquine-primaquine) for 28 days after leav-
ing the high-risk area.

Because certain strains of P. falciparum,
found in Southeast Asia (and in South America),
are resistant to chloroquine, as well as to almost

From the Departments of Preventive Medicine and
Medicine, University of Mississippi School of Medi-
cine.

Read before the Section on Preventive Medicine, 101st
Annual Session. Biloxi, May 14, 1969.

all of the synthetic antimalarials including
Quinacrine, Proguanide, Pyrimethamine, Amo-
diaquine, and Primaquine, some of these re-
turnees will experience clinical disease due to
P. falciparum. These infections may show little

Troops returning by jet to the United
States from service in Vietnam may easily
arrive home during the incubation period of
a number of tropical diseases. The author
discusses the symptoms and treatment of
malaria, melioidosis , leptospirosis, tsutsuga-
mushi disease, Japanese B encephalitis and
other communicable diseases found in Viet-
nam.

clinical improvement or drop in parasitemia lev-
els after 1.5 gm. (base) of chloroquine in three
days. Parenteral administration of chloroquine
also proves ineffective. Recrudescence rates range
from 50 per cent to 80 per cent after chloroquine
therapy.

Fatalities due to P. falciparum malaria have
been increasing in the USA during the past few
years. Dangerous levels of parasitemia occur
with incredible rapidity, leading to complications
such as cerebral malaria, acute renal insufficiency,
massive intravascular hemolysis, disseminated
intravascular coagulation, or acute pulmonary
edema with pleural effusion.

8

JOURNAL MSMA

A high index of suspicion for malaria must be
maintained when troops from Southeast Asia be-
come ill. This also holds true for tourists, seamen.
Peace Corps volunteers and airline crews. Re-
peated thick as well as thin blood smears should
be obtained and studied, in order to rule out ma-
laria, in any illness developing among such per-
sonnel. An accurate species diagnosis is neces-
sary since the drug of choice for Vivax or Quar-
tan malaria is still Chloroquine, 1.5 gm. of the
base (or 2.5 gm. of the salt) in 3 days. Then
Primaquine 15 mg. daily for 14 days, being ef-
fective against the exoerythrocytic or tissue
stages or all malaria species, usually accom-
plishes a radical cure of vivax and quartan ma-
laria.

For chloroquine resistant strains of P. falci-
parum malaria, combined drug therapy utilizing
at least two antimalarials is required, at least un-
til more ideal therapy is available. Currently
quinine is once again the drug of choice for any
individual who subsequently develops P. falci-
parum malaria contracted in Southeast Asia.
Quinine, 650 mg. every eight hours, for 10 days
(total 20 gm.) is given concurrently with pyri-
methamine 25 mg. twice daily for the first three
days (total 150 mg. in 3 days). Beginning on
day seven diaminodiphenylsulfone, (currently
available only in military hospitals) 25 mg. daily,
is begun and continued for the next four weeks
(28 days).

FALCIPARUM MALARIA

In patients seriously ill with falciparum ma-
laria, marked electrolyte and hemodynamic
changes occur. Careful monitoring of fluid intake
and output and daily recording of body weight
is indicated. In the critically ill, measurement
of central venous pressure is helpful in the
avoidance of fluid overloading.

If oliguria develops the use of the osmotic di-
uretic mannitol, following adequate hydration,
appears helpful in restoring sufficient urine out-
put to prevent oliguric renal failure. However,
if a test dose of 20 gm. (as a 20 per cent solu-
tion) of mannitol does not produce a urine vol-
ume of at least 60 ml/hr for each of the next
two hours, fluids should be restricted and the
patient treated as for acute renal failure.

Dennis et al. have demonstrated a rapid con-
sumption of coagulation factors plus evidence of
a defibrination syndrome in patients critically ill
with P. falciparum malaria. In view of this evi-

dence that disseminated intravascular coagula-
tion occurs in such patients, the cautious admin-
istration of heparin (0.5 mg/kg intravenously
every eight hours) would appear to be indicated.
Both animal and clinical experience support this.

In cerebral malaria, or when the acutely ill
falciparum malaria patient is unable to take or
retain quinine orally, the initial dosage of quinine
should be given intravenously. Rapid intravenous
administration of quinine may prove disastrous.
If given slowly, preferably by infusion, in dosage
not exceeding 640 mg. every eight hours, the
drug is well tolerated, provided urine output is
adequate. If severe oliguria or anuria is present,
dangerous quinine blood levels may result. Oral
administration is to be resumed at the earliest
practicable moment.

MASSIVE HEMOLYSIS

Massive hemolysis with marked hemoglobi-
nuria has occurred in nonimmune American
soldiers during the primary attack of P. falciparum
malaria, with or without quinine therapy. The
use of adrenal steroid therapy, such as dexa-
methasone, has appeared to be useful. Carefully
matched transfusions, preferably of packed eryth-
rocytes, may be useful in correcting anemia
that is of life threatening severity. If the blood
smear shows parasitemia, quinine should be cau-
tiously administered. In many of the “blackwater
fever” cases in or from South Vietnam, para-
sitemia has been demonstrated.

Dexamethasone has been effective in the man-
agement of the cerebral edema occurring in cere-
bral malaria. Rapid reversal of choked discs and
clearing of the sensorium has been noted. In the
management of a person having just returned from
South Vietnam, who is acutely ill with falciparum
malaria, a careful search also is indicated for com-
plicating or coexisting acute infectious diseases.

AVAILABILITY OF QUININE

A brief telephone survey of hospital pharma-
cies in Mississippi failed to locate quinine di-
hydrochloride for intravenous use, except for the
Veterans Administration Hospital in Jackson. Qui-
nine sulfate for oral use was available in only a
few. It is suggested that preparations of quinine
for both oral and intravenous use be stocked in
every pharmacy for emergency therapy of chloro-

JANUARY 1970

9

VIETNAM RETURNEES / Blount

quine resistant strains of falciparum malaria. It
is further suggested that valuable time not be
lost by the trial of chloroquine therapy for P. fal-
ciparum malaria imported from Southeast Asia.

Anopheline vectors are present in some parts
of every one of the continental United States.
Thus there is the possibility of these indigenous
vectors becoming infected with not only P. vivax
gametocytes, but with gametocytes of chloro-
quine resistant strains of P. falciparum malaria.
This could lead to outbreaks of malaria due to
mosquito transmission of these introduced strains
of malaria.

Fortunately, it has been proven that one dose of
45 mg. of primaquine base will render adult
gametocytes non-infective for mosquite vectors
for a period of at least 12 days. If each individ-
ual, returning from Southeast Asia, will take one
chloroquine primaquine tablet each week for
eight weeks, as instructed, the sporontocidal
effects of primaquine should effectively prevent
infection of indigenous anophelines. This at least
reduces the threat of malaria once again becom-
ing endemic in the United States.

MELIOIDOSIS

Another disease that should be suspected in
any febrile returnee from Southeast Asia is mel-
ioidosis. This disease, endemic in Southeast Asia,
is caused by the motile, bipolar, poorly staining
gram negative bacillus Pseudomonas pseudomal-
lei. Some 100 cases were recognized in the French
forces in Indochina between 1948 and 1954. Ap-
proximately 140 cases have occurred in American
Armed Forces personnel. There is serological
evidence of many inapparent infections especial-
ly among the South Vietnamese. The clinical
manifestations are protean, ranging from a ful-
minant septicemia, with multiple visceral and
cutaneous abscesses as well as pneumonia, to a
relatively mild pulmonary infiltrate that may
mimic tuberculosis. Acute suppurative arthritis,
cutaneous ulcers, osteomyelitis, or draining si-
nuses of skin, muscle and bone may appear. Sev-
eral recent burn evacuees to the Brooke Army
Burn Center, all without evidence of pulmonary
lesions, have developed septicemia due to Ps.
pseudomallei.

The organism is often easily recovered, using
ordinary culture media from sputum, cutaneous
and other abscesses, or ulcers, or from the blood

stream. Whitish mucoid colonies develop char-
acteristic wrinkling within 4 or 5 days. The cul-
ture medium of choice appears to be eosin meth-
ylene blue (EMB), and the initial culture has in-
variably required a minimum of 48 hours incu-
bation. Serologically, culture proven cases usual-
ly develop hemagglutination titers of 1:40 and
above, and complement fixation titers of 1:8 or
above.

FULMINANT INFECTIONS

Most of the fulminant infections with high
spiking fever, septicemia and multiple visceral
abscesses have occurred in troops in South Viet-
nam. So far in the United States, except for the
burn cases, the few returnees from South Vietnam
who have developed clinically proven melioidosis
usually have shown an onset with fever, and
cough, productive of scanty purulent blood
streaked sputum, together with pleuritic pain.
Chest films in those with pulmonary changes
have shown infiltrates varying from diffuse ir-
regular nodular densities to an almost lobar
pneumonic consolidation. Cavitary lesions are not
infrequent. Most of these cases have shown rapid
improvement on full doses of multiple antibiotic
therapy. Based on sensitivity studies and clinical
observations, effective antibotics in therapy of mel-
ioidosis are tetracycline, chloramphenicol, kana-
mycin. novobiocin, and sulfisoxazole. Almost
uniform resistance has been observed against
penicillin, ampicillin, cephalothin, colistimethate
and streptomycin.

In the critically ill patient, massive doses of a
combination of antibiotics such as chlorampheni-
col, tetracycline and sulfisoxazole, have led to
recovery in few cases, but these fulminant infec-
tions have shown a high mortality rate. In most
of the returnees to the United States, the illness
has shown a subacute pulmonary lesion, respond-
ing well to combinations of antibiotic therapy.
Bennett of the Communicable Disease Center has
reported that chloramphenicol and kanamycin in
combination are antagonistic, at least in vitro.

LEPTOSPIROSIS

Clinical cases of leptospirosis varying in se-
verity from mild episodes of an “aseptic menin-
gitis”-like syndrome to an icteric state with se-
vere liver and kidney involvement may occur in
men who have served in the Mekong Delta. A
large proportion of infections are inapparent.

10

JOURNAL MSMA

The signs and symptoms of leptospirosis are
generally non-specific. After an incubation pe-
riod usually of 10-12 days, but ranging from 3
to 30 days, the onset may be insidious or abrupt.
A rising fever accompanied by chills, myalgia,
headache, and malaise is common. An early
leptospiremia persists for approximately 6 to 8
days, occasionally for two weeks. During the
first week the organisms may sometimes be
found in the cerebrospinal fluid. Fever of 102 to
104 degrees F may persist for several days to a
week. During the leptospiremic period conjuncti-
val suffusion, retro-orbital pain, pharyngitis, mus-
cle tenderness, nausea, vomiting, abdominal pain,
relative bradycardia, adenopathy and nuchal
rigidity are frequently noted. Signs of meningeal
irritation usually appear early and often be-
come pronounced during the second week. There
is increased spinal fluid pressure and a delayed
appearance of lymphocytic pleocytosis. In milder
cases of leptospirosis, meningeal signs frequently
dominated the clinical picture. Such cases prob-
ably might have been termed “aseptic meningitis”
a few years earlier.

CLINICAL IMPROVEMENT

With the disappearance of leptospiremia, clin-
ical improvement occurs, although a secondary
febrile episode may appear. By the 6th to 10th
day detectable antibodies are present. Full re-
covery usually occurs within two weeks in mild
cases. Leptospiras appear in the urine after the
first week of illness. Shedding of leptospiras in
the urine is more pronounced the first weeks after
clinical improvement is noted, but may occur in-
termittently for three or more months thereafter.
In milder cases, a slight leukopenia occurs.
Where there is liver involvement, the white cell
count may be elevated (above 15,000 cells per
cu. mm.) with neutrophilia. Renal findings vary
from a mild transient proteinuria, usually noted
in benign leptospirosis, to a severe nephritis with
hematuria, casts, and oliguria, or even anuria.

Severe nephritis frequently is noted in the ic-
teric form of leptospirosis. Jaundice in these cases
usually develops in the middle or latter part of
the first week. The liver becomes enlarged and
tender. Mucous membrane and cutaneous ecchy-
moses are frequent, and gastrointestinal hemor-
rhage can occur. The mortality in jaundiced pa-
tients who are severely ill ranges from 50 to 30
per cent. Fatal anicteric cases are extremely rare.

Paired or serial sera specimens may reveal a
4 fold (diagnostic) rise in agglutination or com-

plement fixation titer. Leptospira may be isolated
by culture or animal incubation of blood or cere-
brospinal fluid in the first week of illness, or from
urine after the first week. Fluorescent antibody
technics are very promising.

No really effective specific therapy is available.
Penicillin is apparently useful only when admin-
istered in the first 48 hours of illness.

TSUTSUGAMUSHI DISEASE

Tsutsugamushi Disease (scrub typhus), a mite-
borne rickettsial disease, was seen in great num-
bers by medical officers in the South and South-
west Pacific in WWII. Cases currently appear
among troops who have been operating in cer-
tain grasslands areas of South Vietnam. A small
eschar 0.5 to 1.0 cm. in diameter usually indi-
cates the site where the infected mite took a blood
meal. On or about the 5th day of this febrile ill-
ness a faint erythematous macular rash may ap-
pear for a few hours. The leukocyte count is
usually not remarkable. Paired sera should be
obtained and a four-fold rise in the OXK (Weil-
Felix) titer is considered diagnostic. A rise in
OXK titer may also occur in leptospirosis and in
mite-borne relapsing fever. Tetracycline usually
produces a prompt defervescence. Tetracycline
therapy does not prevent a subsequent diagnostic
rise in serologic titer. The mortality rate from
clinical illness due to the South Vietnam strain
of Rickettsia tsutsugamushi (orientalis) is quite
low compared to that of strains found in the
Southwest Pacific.

JAPANESE B ENCEPHALITIS

A very few cases of Japanese B encephalitis
have occurred among American troops in South
Vietnam. This mosquito-borne virus disease may
present as a severe diffuse encephalomyelitis.
Many inapparent infections may occur simul-
taneously. Paired sera should be obtained for
serologic diagnosis.

Complement fixing or neutralizing antibodies
develop. The virus can be often recovered from
the brain of fatal cases. Therapy is symptomatic
and supportive.

Some intestinal helminthiasis may be expected
among Vietnam returnees. Hookworm infestation
may be responsible for considerable epigastric
distress. With the stools showing occult blood,
the diagnosis of peptic ulcer has been suspected.
In a number of cases, a peripheral blood eosino-

1 1

JANUARY 1970

VIETNAM RETURNEES / Blount

philia has directed attention to the possibility of
intestinal parasitism. Ascariasis, strongyloidiasis
and trichuriasis may also appear among returnees.

TROPICAL SPRUE

A few cases of tropical sprue have been recog-
nized among American service men returning
from Vietnam. Should such a returnee show a per-
sistent diarrhea, and no demonstrable pathogens,
a d-zylose absorption test is indicated. A Sudan
IV stain of a fecal smear may show neutral fat
globules, or fatty acid crystals. A biopsy speci-
men of jejunal mucosa may show villous atrophy,
or flattening. Cases of tropica! sprue usually fail
to respond to a gluten free diet. Most of the cases
from South Vietnam have responded to 15 mg.
daily dosage of folic acid given over a 12-week
period. The acutely ill patient with severe diar-
rhea and weight loss should also be given tetra-
cycline 1 gm. daily for 30 days followed by 0.5
gm. daily for another 5 months plus folic acid. 15
mg. daily and vitamin Bi2 30 micrograms intra-
muscularly each week for six months.

HIGH PLAGUE INCIDENCE

With an enormous plague infected rodent res-
ervoir in South Vietnam, a high incidence of
plague among the Vietnamese is not unexpected.
American troops have received an effective
plague vaccine and so far have developed only
three clinical cases of the disease. Two of these
presented with fever and inguinal adenopathy;
all three cases survived. Plague should be sus-
pected in any returnee who develops a febrile
illness and a regional adenopathy within 10 days
of his departure from Vietnam. Needle aspira-
tion of the bubo may permit recovery and identi-
fication of the Pasteurella pestis by smear, cul-
ture, and/or animal inoculation. Immunofluores-
cent staining provides a highly specific, quick and
reliable means of diagnosis. Although strains of
P. pestis in South Vietnam have shown some in-
crease in resistance to streptomycin in vitro, this

antibiotic is still the drug of choice. Large doses
(0.5 gm. IM of 3 h for 2 days followed by 2 gm.
daily for 10 days) are recommended.

TUBERCULOSIS

There is a high incidence of tuberculosis
among the Vietnamese. Many American troops
have been tuberculin tested. Those with records
of negative intradermal tuberculin (purified pro-
tein derivative) should be retested annually for
several years. Those with positive intradermal
tests should have annual chest x-rays. Recent
converters should be treated.

Schistosomiasis has not yet proven to be en-
demic in South Vietnam. Infectious hepatitis in a
relatively mild form has occurred in American
troops. Leprosy does occur among the Vietnam-
ese, but the incidence of leprosy among Ameri-
can returnees is expected to be infinitesimally
low.

Other infectious diseases endemic in South
Vietnam are essentially cosmopolitan in occur-
rence and have not been discussed. ***

2500 North State St. (39216)

REFERENCES

1. Hunter, G. S., Ill; Frye, W. W.; and Swartzwelder,

J. (editors): A Manual of Tropical Medicine, ed. 4,
Philadelphia, W. B. Saunders Company, 1966.

2. Blount, R. E. : Chloroquine Resistant Falciparum
Malaria (editorial), JAMA 200:886 (June) 1967.

3. Blount, R. E.; Alstatt, L. B.; Conrad, M. E.; Blount,
R. E., Jr.; Drew, R.; and Tigertt, W. D.: Panel on
Malaria, Ann. Int. Med. 70:127-153 (Jan. 1) 1969.

4. Weber, D. R.; Douglass. L. E.; Brundage, W. G.; and
Stallcamp, T. C.: Acute Varieties of Melioidosis Oc-
curring in U. S. Soldiers in Vietnam, Am. J. Med.
46:235-244 (Feb.) 1969.

5. Alexander, A. D.; Gochenour, W. S., Jr.; Reinhard,

K. R.; Ward, M. K.; Yager, R. H.: Am. Public Health
Assn. Diagnostic Procedures and Reagents, Chapter
on Leptospirosis, ed. 5, 1969.

6. Gilbert, D. N.; Moore, W. L.; Hedberg, D. L.; and
Sanford, J. P.: Potential Medical Problems in Per-
sonnel Returning from Vietnam, Ann. Int. Med.
68:662-678 (March) 1968.

7. Greenberg, J. H.: Public Health and the Vietnam
Returnee, JAMA 207:697.

8. Dennis, L. H., et al: A Coagulation Defect and Its
Treatment with Heparin, in Malaria, Military Medi-
cine 131:1107-1110 (Supplement).

A complete bibliography will be furnished on request
to the author.

1 2

JOURNAL MSMA

Modern Concepts in Treatment
Of Respiratory Insufficiency

G. B. SHAW, M.D.
Jackson, Mississippi

In the past several years there has been a
great emphasis on the treatment of respiratory
insufficiency. This has come about for several
reasons. First, there is an increasing incidence
of obstructive lung disease in the population in
general. Second, there is increased information
coming from the research lab, leading to improved
knowledge in the complex problems involved in
respiratory insufficiency. Third, better instruments
are available giving quicker results on various
parameters used to follow the patient with this
condition. Finally, there is increasing sophistica-
tion in the instruments and machines used in
managing these patients. All of these factors
have culminated in improved methods in caring
for the patient with respiratory insufficiency.

Respiratory failure is not a disease per se, but
a syndrome of ineffective lung function due to
many causes. The literature defines respiratory
failure in terms of a P02 less than 50 mm. Hg.
and/or PCOL» greater than 50 mm. Hg. This suf-
fers the same drawback as trying to define uremia
as a BUN above a certain number or congestive
heart failure as an end-diastolic pressure of great-
er than a certain figure. Nevertheless, we need
specific values in order to quantitatively appraise
the problem.

For the most part respiratory failure is thought
of as the end result of obstructive lung disease.
However, there are numerous causes of respira-
tory failure which may be a result of dysfunction

Read before the Section on Medicine, 101st Annual Ses-
sion, Mississippi State Medical Association. Biloxi,
May 14. 1969.

of any of the organs responsible for respiratory
effort.

In the brain, the respiratory center is respon-
sible for initiating the inspiratory effort. Though
many things are known to act on this center.

Many changes in the handling of patients
with respiratory insufficiency have developed
in the last several years as a result of im-
proved understanding of the pathophysiol-
ogy of the problem. The causes of respira-
tory failure are reviewed and management
discussed.

there remains a large gap in the knowledge of
this complex system. Among the conditions
known to affect the respiratory effort are pri-
mary alveolar hypoventilation, and its related
condition, the Pickwickian syndrome. Overdosage
of certain drugs including sedatives, tranquil-
izers and narcotics are known to depress respira-
tion. Additionally, certain other conditions such
as brain trauma and cerebrovascular accidents
may well be a cause for respiratory insufficiency.
The spinal cord may be involved with a number
of conditions such as poliomyelitis, Guillain-Barre
syndrome, trauma and spinal anesthetics. Periph-
eral neuritis and myasthenia gravis may cause
respiratory failure.

Distortion of the thoracic cage with kyphoscoli-

JANUARY 1970

1 3

Respiratory Insufficiency / Shaw

osis, various kinds of trauma and especially the
flail chest may lead to under-ventilation. Changes
occurring in the pulmonary circulation, which
may include pulmonary embolus, and acute left
ventricular failure, caused by myocardial infarc-
tion, may precipitate respiratory failure. Finally,
the many types of lung disease including pneumo-
thorax, pleural effusion, progressive pulmonary
fibrosis and obstructive lung disease may all even-
tuate in respiratory failure. So it is obvious that
any condition of proper severity involving any of
the organs effecting the respiratory system may
produce a state of respiratory insufficiency.

Oxygenation of the body is one of the two
main functions of the lung. Several terms which
are used in describing the state of oxygenation
include oxygen content, oxygen saturation, and
oxygen partial pressure. The oxygen content is
the actual volume of oxygen per 100 cc. of blood.
In normal arterial blood this is 19.5 cc. per cent,
assuming a normal hemoglobin of 15 gm. Any
reduction of hemoglobin would reduce the oxygen
content of blood. Normal oxygen saturation is 95
per cent, indicating 95 per cent of the hemoglobin
in the arterial system is saturated with oxygen.

OXYGEN PRESSURE

The partial pressure of oxygen relates to the
amount of dissolved oxygen in the plasma and is
directly related to the oxygen saturation. It is
the partial pressure of the oxygen which is im-
portant, for it is the pressure gradient from the
lung to the capillary which is responsible for the
passage of oxygen across the alveolar-capillary
membrane. Likewise, the pressure gradient at
the systemic capillary level is responsible for the
oxygen passing from the peripheral capillary
into the tissues. The recent availability of the
Clark electrode to measure P02 directly in ar-
terial blood makes this measurement much eas-
ier. Normal values for arterial blood is 85 to
95, decreasing slightly in the older patient.

The diagnosis of hypoxemia presents many
problems. The hypoxemic patient may demon-
strate irritability, slight confusion, a loss of judg-
ment, especially in dangerous situations, and per-
haps even violent behavior. The only specific
clinical sign of hypoxemia is cyanosis, which oc-
curs only in the severely hypoxemic patient.
The only accurate method of diagnosing this
problem is arterial blood gas measurements.

What levels of hypoxemia may be dangerous?

Hypoxemia occurs at a P02 of about 60. Cyano-
sis, which is the only definite sign of hypoxemia,
occurs at a P02 of 50. As POL> continues to drop,
tissue injury can be demonstrated with eleva-
tion of SGOT and other enzymes. Finally, a P02
of 20 is incompatible with life. It should be re-
membered that these are only guides — a normal
person rendered acutely hypoxic may die with a
P02 of 40. Conversely, a chronically hypoxemic
patient might be fairly comfortable at the same
POo.

TREATMENT OF HYPOXEMIA

The treatment of hypoxemia is rather easy.
It simply involves increasing the oxygen con-
centration the patient is breathing. Though there
are many methods of administering the oxygen,
the one most commonly available to most hos-
pitals and physicians is the nasal cannula. Heated
nebulizers furnishing 40 per cent oxygen concen-
tration are also quite effective. Oxygen tents, for
the most part, have no place in this condition,
for it rather effectively isolates the patient which
hinders effective respiratory care. Several prin-
ciples should be emphasized. In the usual patient
in respiratory insufficiency, only very small in-
creases in the oxygen concentration are neces-
sary. Usually oxygen at a rate of 2-3 liters per
minute is entirely sufficient to prevent hypox-
emia. Secondly, if a patient is hypoxemic, he re-
quires oxygen continuously. This includes periods
of eating, bathing, exercise and bathroom privi-
leges. A third principle which should be em-
phasized is the hazard of using too high a con-
centration of oxygen. If a patient is in severe
distress and is breathing from a hypoxic drive,
then use of too high concentrations of oxygen
may lead to further respiratory depression.

ELIMINATION OF C02

The elimination of C02 from the body is the
second function of the lungs. The body is almost
completely dependent on the lungs to carry out
this function. As the result of aerobic metabolism,
the body produces approximately 100 cc. of
C02 per square meter of body surface area which
amounts to about 200 cc. in a 70 kilogram man
per minute. The body is dependent on alveolar
ventilation to eliminate the C02: alveolar venti-
lation = Produced^^63 c°2 . jf alveolar ventilation
is decreased, then the body levels or partial
pressure of C02 increases. Therefore, the PCOo

1 4

JOURNAL MS M A

in arterial blood is a function of alveolar venti-
lation. The PC02 is directly proportional to the
carbonic acid in the blood, and therefore, any
rise in PC02 produces a rise in carbonic acid
which therefore increases the hydrogen ion con-
centration causing an acidosis.

This is related through the Henderson-Hassel-
balch Equation: H*(aonomoles)=24 F^-Q(m(nieqf *
Though this does not look like the familiar Hen-
derson-Hasselbalch equation, it is another way
of writing the equation. In looking at this it can
be seen that an increase of the PC02 on the right
side increases the hydrogen concentration. If the
PC02 rises due to inefficient alveolar ventila-
tion, then the patient will immediately develop
a respiratory acidosis. The bicarbonate as de-
picted in the formula is a function of the kid-
neys. If the PC02 rises, then the kidneys func-
tion to increase the bicarbonate in an effort to
compensate for the acidosis and return the hy-
drogen ion concentration or ph toward a more
normal figure. The dynamics of the system are
important. If respiration is cut in half, there is an
immediate and sustained rise in minutes of the
PC02. However, the kidney functions in a period
of hours to days rather than minutes, and there-
fore, compensation always lags in insufficient
breathing.

C02 RETENTION

The clinical diagnosis of C02 retention is dif-
ficult with many non-specific symptoms and
signs. When significant C02 levels develop, the
patient becomes increasingly drowsy, and as the
PCOL» approaches 90, the patient will progress
into a coma. Asterixis or a flapping tremor is not
peculiar to liver disease alone. A rather typical
flap may be seen in a patient in respiratory fail-
ure. In the late stages of C02 retention, papil-
ledema may be produced due to increased cerebral
vasodilitation with increased blood flood. As in
hypoxemia, the only true and accurate method
of determining C02 states is the measurement
of blood gas. Arterial blood is preferable, but
venous blood may be sufficient in measuring the
PC02, unlike hypoxemia where arterial blood is
mandatory.

There are several principles which should
be mentioned. Any elevation of PC02 means the
patient is hypo-ventilating. Secondly, any eleva-
tion of PC02 renders the patient hypoxemic.
From the alveolar air equation: PACE = Fi,,2
P(B-H20) - PACCE x 1.2, a PC02 at a normal
level of 40 reduces the oxygen from 140 in room

air to approximately 90 in the arterial blood; on
the other hand, if the PC02 is 80, the C02 dis-
places oxygen in the alveolar rendering the pa-
tient much more hypoxemic.

Though the treatment of hypoxemia is easy
with the administration of oxygen, the treat-
ment of excess C02 retention is a more difficult
clinical problem. If the cause of the respiratory
insufficiency is acute, such as trauma, then venti-
latory assistance is mandatory. In the emergency
room, this might be the Ambu bag or mouth to
mouth breathing. In the operating room, this
may be the anesthesia machine. The IPPB ma-
chines have enjoyed increasing popularity over
the past several years. If the patient is alert and
cooperative, perhaps a face mask or mouth
piece will be sufficient, though one could use this
only for limited periods of time.

TRACHEAL INTUBATION

If this should not prove an effective method,
then tracheal intubation with an anesthesia type
endotracheal tube would be in order. With proper
care and due precautions, these tubes may be
left in place for several days. As a general rule
of thumb, if the tube is needed more than two
days, conversion to a tracheostomy seems to
be indicated; however, many cases have been
treated with tubes for up to one week without
undue problems. There are complications from
the tubes, and these may present early or late.
Finally, the tracheostomy may be indicated, and
it is well recognized that these are not without
complications also.

PRINCIPLES OF MANAGEMENT

In the more chronic problems such as emphy-
sema, where the lungs are diseased, it may not
be possible to return the patient to a normal
blood gas state. Principles of management are
slightly different. The first principle is to clean
the tracheo-bronchial tree. If the patient is
awake and coughing, then full advantage is
taken of this. If he is too weak to cough, naso-
tracheal suction may well be lifesaving. Various
stimulants including ethamivan or dextroamphet-
amine may increase his level of consciousness,
and therefore improve his ventilatory effort. Var-
ious physical therapy maneuvers also assist in
more effective ventilation and drainage of the
tracheo-bronchial tree. Finally, if these methods

1 5

JANUARY 1970

Respiratory Insufficiency / Shaw

in the chronic patient are ineffective, supported
respiration with the respirators may be neces-
sary.

THE IPPB MACHINE

Since the mid-1950s, when the value of IPPB
machines was first recognized during the polio
epidemic in the Scandinavian countries, much
improvement has occurred. The cost of the IPPB
devices ranges from $50 to $5,000 depending
on the qualities and sophistication desired. The
two main functions served by the IPPB machine
are: (1) providing a deep breath and (2) pro-
viding a vehicle for medication. Though it is not
the purpose of this paper to discuss these ma-
chines, certain principles should be mentioned.

The pressure necessary to ventilate a patient
in various conditions differs. A pressure of 15 cm.
Hl.O may be adequate for the obstructed patient
with big overdistended lungs. On the other hand,
the “stiff lung” as seen in pulmonary edema,
pulmonary fibrosis, and other conditions may
require pressures of 30-50 cm. Hv>0, and occasion-
ally pressure of 120 cm. H>>0, may be necessary.

Secondly, despite the manufacturers’ claim of

delivering a 40 per cent 0_> concentration, this is
not so, except on the newer and more expensive
machines. The average CX concentration deliv-
ered is between 50-60 per cent; so this, in effect,
is uncontrolled CT. Compressed air rather than
CX is adequate in most cases. Some type of
moisture is necessary to keep from drying the
tracheo-bronchial tree. A side arm medication
nebulizer is completely insufficient. A main stream
nebulizer or humidifier is most desirable.

Infection is increasingly recognized as a prob-
lem. Gram negative organisms have been found
as a cause of a necrosing pneumonitis. The
source of infection, in most cases, is in the main
stream nebulizers. Careful monitoring at regular
intervals is essential in insuring the machines are
free of bacterial contamination.

SUMMARY

In summary, many important and improved
changes in the respiratory insufficiency prob-
lem have come about in the past several years.
All of these changes are based on improved un-
derstanding of the pathophysiology of the prob-
lem. If these pathophysiology changes are under-
stood, then a more rational approach to therapy
is possible. ***

440 East Woodrow Wilson (39216)

RESTFUL REST ROOM

Stopping at a rural service station, the motorist asked, “Do
you have a rest room?”

“Nope,” said the attendant. “When any of us git tired we jes
sit on one of them oil drums.”

16

JOURNAL MSMA

Cancer Quiz

Cancer Committee
University Medical Center
Jackson, Mississippi

This feature, consisting of review questions re-
lated to the cancer field, was prepared by the
Cancer Committee of the University Medical
Center. Answers appear on a separate page.

Questions from readers related to these re-
view questions may be submitted to the Edi-
tors of the Journal for forwarding to the com-
mittee. Each will receive a personal reply. Suit-
able questions from readers will be considered
for publication. This initial presentation relates
to general cancer statistics, based on data pub-
lished by the American Cancer Society.

Comment and suggestions are invited from
readers. — The Editors.

1 ) In the United States, cancer deaths represent

approximately what per cent of total deaths:

a) 5%

b) 15%

c) 25%

d) 35%

2) These cancer deaths represent a total num-
ber in the range of:

a) 100,000

b) 300.000

c) 500,000

d) 700.000

3) The annual U. S. death total, if expressed

in deaths per unit of time, would be:

a) One death per 1 minute

b ) One death per 2 minutes

c) One death per 5 minutes

d) One death per 10 minutes

4) The mortality rate, male to female is:

a) 50% men/50% women

b) 45% men/55 % women

c) 45% men/45 % women

d) 60% men/40% women

5) The two leading causes of cancer deaths
in the U. S. A. are:

a) breast cancer

b ) cervix cancer

c) lung cancer

d) rectal-colon cancer

6) The two leading causes of cancer deaths
among American men are:

a) lung cancer

b ) rectal-colon cancer

c) Hodgkin's disease

d ) stomach cancer

7 ) The leading two causes of cancer deaths
among American women are:

a) lung cancer

b) breast cancer

c) cervix cancer

d) rectal-colon cancer

8) Incidence data shows the most common can-
cer is:

a) lung cancer

b ) breast cancer

c) cervix cancer

d) skin cancer

9) Approximate annual total cancer deaths in
Mississippi is:

a) 1,000 per year

b) 2,000 per year

c) 3,000 per year

d) 4,000 per year

10) If your patient community consists of 5,000
people, the approximate number that will
be under cancer care during the next year is:

a) 10

b) 20

c) 30

d) 50

(Answers on page 49)

JANUARY 1970

17

Radiologic Seminar XCI:
Tracheoesophageal Fistula

WALTER T. COLBERT
Natchez, Mississippi

Tracheoesophageal fistula (TEF) occurs
once in 3000 births, and in over 95 per cent of
instances is associated with atresia of the esopha-
gus. This anomaly is one of the most frequent
congenital defects, which, if left untreated, will
be uniformly fatal in the neonatal period.

There are two conditions which may herald the
birth of a child with esophageal atresia and
tracheoesophageal fistula-polyhydramnios and
prematurity. Commonly associated anomalies
that should be recognized at birth are congenital
heart defects, imperforate anus, arm and hand
anomalies, and clefts of the lip and palate. In
babies born of mothers with polyhydramnios a
routine part of the neonatal examination must in-
clude the passage of a nasogastric tube and veri-
fication of its presence in the stomach by x-ray.
The same procedure should be followed in the
routine examination of premature babies or those
born with any of the above mentioned malforma-
tions.

In a majority of infants with esophageal atresia
and TEF anomalies the diagnosis will be sug-
gested by the following signs. Apparently exces-
sive mucus will usually be the first clinical sign,
as all of the mucus must be regurgitated in in-
stances of esophageal atresia. These infants will

Sponsored by the Mississippi Radiological Society.

From the Department of Radiology, Natchez General
Hospital.

also cough, choke, and may become cyanotic
when fed. These findings will frequently be no-
ticed by personnel in the nursery. It is important
that the diagnosis be made promptly, as the pre-
vention of pneumonitis by appropriate therapy
is mandatory if these infants are to be salvaged.

The diagnosis can be established definitely by
failure of passage of a radiopaque catheter into
the stomach. If the tube cannot be passed into
the stomach and verified as to position by radio-
logic means, a small amount of opaque material
can be introduced into the catheter and the site
of esophageal atresia will be demonstrated. In
those instances where there is no associated
esophageal atresia — a relatively small percent-
age— the diagnosis will depend upon actual con-
trast filling of the communication between the
esophagus and trachea. This can be accomplished
by the injection of opaque material through a
catheter in the upper esophagus, with care being
taken to avoid spillage of the opaque material
over the epiglottis.

CASE I — This two day old male infant was
noted by the nursery personnel to cough, choke
and become cyanotic whenever feeding was at-
tempted. TEF was suspected clinically, and a
catheter was passed easily into the stomach ex-
cluding the presence of esophageal atresia.
Opaque material (micropaque) was then intro-
duced through an esophageal catheter, and a di-
rect communication between the upper esophagus
and trachea was demonstrated. The patient was

1 8

JOURNAL MSM A

Case I — Figure 1. Oblique views
of the barium-filled esophagus demon-
strate beginning, and subsequent en-
thusiastic filling of the tracheobron-
chial tree through the tracheo-esopha-
geal communication (arrow). Opaque
material was introduced into the
esophagus using a balloon catheter in
order to prevent aspiration of opaque
material over the epiglottis.

Case I — Figure 2. Chest film made
immediately following the fluoroscopic
procedure: an unintended, but normal
bronchogram is noted. The lung fields
were grossly clear in approximately 72
hours.

JANUARY 1970

19

HEH H02b

Case II — Figure 1 . Oblique views
of the chest with contrast material in
the esophagus demonstrate a blind
pouch, with no communication with
the tracheobronchial tree. The patient
did not aspirate any of the opaque
material over the epiglottis.

Case II — Figure 2. A routine chest
and abdomen film demonstrate rela-
tive over-expansion of the lung fields,
and considerable gas throughout the
gastrointestinal tract. This finding in-
dicated a definite communication be-
tween the tracheobronchial tree and
GI tract below the site of obstruction
demonstrated on the contrast study.

20

JOURNAL MSM A

treated surgically, with primary closure of the
fistulous communication. This type of tracheo-
esophageal fistula comprises only 4 per cent of
the TEF anomalies.

CASE II — This new born female infant was
noted to have “excessive mucus” immediately
after birth. It was not possible to pass a catheter
into the stomach, and opaque material intro-
duced into the pharynx demonstrated a blind
pharyngo-esophageal pouch, with no communi-
cation between the atretic esophagus and the
tracheobronchial tree. A film of the chest and
abdomen, however, demonstrated over-expan-
sion of the lung fields, and considerable gas
throughout the entire GI tract. This finding indi-
cated a definite communication of the GI tract with
the tracheobronchial tree distally. These findings
were verified at the subsequent surgical proce-
dure. This type of tracheoesophageal fistula com-
prises approximately 87 per cent of the TEF
anomalies.

The two cases noted above are fairly typical
examples of the TEF anomalies that present
themselves in the immediate neonatal period,
and which can be diagnosed promptly by roent-
genologic means.

SUMMARY

Tracheoesophageal fistula and esophageal
atresia are neonatal emergencies which can be
diagnosed promptly by roentgenologic means.
While uncommon in occurrence, prompt recog-
nition is necessary for survival of these infants.
Pneumonitis remains the usual cause of a fatal
outcome in these anomalies, but this complica-
tion can be prevented by prompt recognition of
the fistula and appropriate treatment. ***

Jefferson Davis Memorial Hospital (39120)

BIBLIOGRAPHY

Holder, Thomas M., and Ashcraft. Keith W. : Current
problems in surgery. Chicago. Yearbook Medical
Publishers, Inc., 1966.

PROFESSIONAL GRATUITY

Called by his draft board, a young man was examined by his
family doctor who happened to be on the board. He passed easily
and was inducted, which burned him up.

Next day he phoned the doctor and said. “You're one heck of a
doctor. It’s funny you always found something wrong with me
when I was paying to visit you!"

JANUARY 1970

21

The President Speaking

‘Needed Now’

JAMES L. ROYALS, M.D.

Jackson, Mississippi

The first three days in December the AMA held its annual
clinical convention in Denver. In addition to your delegates, sev-
eral of your officers attended. On Saturday, preceding the regular
meeting, there was an all day conference on peer review. This
was a most enlightening conference, which revealed to us that prob-
lems physicians face are more or less the same throughout our
nation.

The afternoon part of this meeting was composed of two dem-
onstrations by peer review committees, one a committee from a
hospital staff as it functioned in reviewing the in-hospital activities
of its staff members and the other a peer review committee from
a county medical society as it dealt with problems relating to
a broader aspect of our health care system. These interesting
demonstrations revealed the degree to which organized medicine
in other areas of the country are dealing with pressing and some-
times painful problems within its own ranks.

It is essential, if medicine hopes to continue as a free enter-
prise, to improve its own peer review so as to assure a continuing
up-grading of quality medical service. I find that Mississippi is
behind the other states in the application of peer review and
urge that medical staffs and component medical societies move
rapidly ahead in this urgently needed area of self-analysis.

22

JOURNAL MSMA

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI. NUMBER 1
January 1970

Medicaid in Mississippi:
A Bare Bones Beginning

I

The first day of 1970 will be more remark-
able for eight hours of bowl games on television,
family gatherings, and a few headaches from the
festivities of New Year’s Eve than for the incep-
tion of the $33.7 million Medicaid program in
Mississippi. For all intent and purpose, the date
is so much statutory rhetoric, because the pro-
gram will not be fully operational before spring
or perhaps summer. It is a bare bones beginning.

The Mississippi Medical Assistance Act of
1969, House Bill 2 of the Extraordinary Session
of the Legislature, is the legal mouthful for
Medicaid. Its birth pains were harsh as the so-
lons debated with spirit — and sometimes acri-
mony— from July 22 through Oct. 11. It ex-
ists only because of administration leadership,
an understanding of what had to be done by a
majority of legislators, and the support of the
health care team.

It is a complicated law which implements the
most complex health care program ever devised
by the Congress. The proof of this pudding
shows up in the misunderstanding about it dur-
ing debate in the Legislature. And beyond this.

there were out-and-out hostile efforts openly ex-
erted to cloud the issues and defeat the bill.
But this is mostly in the past tense, as the mecha-
nism of state government has meshed in heroic
effort to get the program off the ground in a mat-
ter of two and one-half months. Almost any
workable result has got to go down in the history
books as a compliment to the John Bell Williams
administration and the newly created Mississippi
Medicaid Commission.

The program director. Dr. Alton B. Cobb of
Jackson, has assembled the nucleus of a compe-
tent staff, initiated communications and working
agreements with providers, coordinated with oth-
er state agencies, and begun the task of building
the substantial fiscal machine necessary to make
as many as 2 million payments per year.

II

For a minimum of three months, only six ser-
vices will be activated:

— Inpatient hospital services.

— Outpatient hospital services.

— Other laboratory and x-ray services.

— Skilled nursing home services.

— Physicians’ services.

JANUARY 1970

23

EDITORIALS / Continued

— Periodic screening and diagnostic services.

Seven other categories of services under the
program are, for the moment, deferred because
of time demands in solving staggering imple-
mentation problems. These are home health ser-
vices for beneficiaries eligible for skilled nursing
home services, emergency ambulance service or-
dered by a physician or law enforcement officer,
legend drugs and insulin, sharply limited dental
services, eyeglasses following eye surgery, inpa-
tient hospital services for those over age 65 in
an institution for tuberculosis or mental disease,
and care and services provided in Christian Sci-
ence sanatoria.

In scope, amount, and duration, services are
generally limited by frequency of utilization, ex-
cept for physicians’ services which are addi-
tionally limited by dollar amounts. Inpatient hos-
pital care is provided for 20 days per fiscal year
with an additional 20 days available on review,
recertification, and approval by the utilization
review mechanism. Outpatient hospital care is
limited to 30 visits per fiscal year.

Stays in nursing homes beyond 90 days must
pass review criteria, and while specific limitations
on laboratory and x-ray services are not men-
tioned, the labs must be certified under Title
XVIII (Medicare).

Ill

Physicians will be compensated for services
rendered in the hospital, nursing home, office,
patient’s home, or elsewhere. Ordinarily, hospital
visits are limited to one per day, and the pro-
gram will pay for a maximum of 36 nursing
home visits per year.

Limitations on home and office visits are not
mentioned, but the Medicaid Commission has
plans for closely supervised utilization review.
Diagnostic laboratory services performed in the
physician’s office are limited to hematocrit, hemo-
globin, routine urinalysis, and WBC.

The Medicaid law prescribes payment for phy-
sicians under the Mississippi Blue Shield F-300
fee schedule, and it is neither complete nor rela-
tive. Generally, the schedule provides payment
around the 50th to as much as the 60th per-
centiles. For the many procedures not covered by
the F-300, the California Relative Value Index
of 1964 will be used with a $4 per point conver-
sion coefficient. In some instances, this will per-
mit professional compensation at as much as
the 70th percentile.

By anybody’s measurement, these are sub-

standard fees, and this has been the pattern
for Medicaid nationally in 1969 following the
HEW-imposed fee freeze. Participation is volun-
tary, of course, and those participating should
charge their usual and customary fees exactly as
charged to private patients, regardless of what
they receive in payment.

Charges at the usual and customary level are
crucially important if we are to avoid a distorted
profile of fee patterns prevailing in Mississippi.
For many years, some physicians charged only
what low option care financing plans would pay
on the shaky assumption that they were expedit-
ing payment of what they would get anyway.
This practice actually worked against the phy-
sician in the matter of his receiving fair profes-
sional compensation, because there was simply
nothing on the books to prove that the real
charges were greater than the parsimonious al-
lowances of the financing mechanism.

IV

It is fair to say that Medicaid in Mississippi is
in a probationary period as it moves onto the
scene to finance health care for about 9 per cent
of the state’s population. For such a massive task,
it is indeed a bare bones program. To make it a
viable mechanism as visualized by the associ-
ation’s House of Delegates in approving it on
two occasions will demand patience, leadership,
and not a little sympathetic understanding.

24

JOURNAL MSMA

The physician is not being fully compensated
for his services under the program — not na-
tionally nor in Mississippi. Through June 30.
1969. total payments to physicians under all
Medicaid programs then operational amounted
to 11 per cent of all combined state and federal
funds expended, while 89 per cent had been
paid to hospitals, nursing homes, pharmacists,
and all other care sources. Two principal and
opposite arguments about professional compen-
sation have been noted in Mississippi:

— When the state buys a tire for a state-
owned vehicle, it pays the price of a tire. When
a shovel is purchased for the Forestry Commis-
sion. the state pays out the price of a shovel.
Hence, when the state purchases an appendec-
tomy, it should pay the going price.

— Since 1936 when the State Hospital Com-
mission program was enacted, physicians have
received nothing for their services to the indigent
in Mississippi and were, in fact, forbidden to
charge, accept payment, or in any manner be
compensated. Under Medicaid, at least a be-
ginning has been made with half a fee or a little
more.

The association has spoken frankly in this
connection: Physicians should be compensated
for services actually rendered with payment of
true usual and customary fees. This will be a
goal in any program — not just Medicaid — which
falls short. But it does not mean that Medicaid
will be ignored or that the association's increas-
ing effectiveness in peer review will be denied
the program. Nor does this infer that support
is grudgingly given, because the word of the
House of Delegates is the association's pledge
and bond. The practicing physician asks only
that a fair shake be afforded him. and he will
carry out his dedication in partnership with his
state. — R.B.K.

The Old Chit-Chat
Gets a Facelifting

The state medical association’s oldest existing
and continuing publication, the Newsletter, has
turned up with its third facelifting. Beginning
with this issue of the Journal, the Newsletter
goes to a three-page format as more or less the
first and last words in each issue. The third page,
entitled “In Conclusion.'’ will be the last page
in each issue.

Newsletter is 19 years old. having made its
initial appearance as a single mimeographed
page in 1951 which was published twice month-
ly. A year later, it showed up as a four-page
monthly publication sent to every member and
continued uninterrupted until December 1959.
When the first issue of the Journal was published
in January 1960, Newsletter appeared as a two-
page bound insert in the front of the book.

After 10 years, the chatty sheet becomes an
integral part of the Journal on three printed
pages. The Editors and Committee on Publica-
tions feel that the new format will give more
flexibility, increase readership, and assist in pro-
duction. The insert was printed at Jackson and
shipped to the Journal printers, sometimes
with teeth-gnashing results. For example. News-
letter was missent by the post office to the wrong
city twice in 1969 and completely lost once some-
where in that rain. snow, sleet, and gloom of night
through which the U. S. mail must traverse.

As with each and every feature, article, and
regular department in the Journal, the News-
letter belongs to the membership. Suggestions,
criticism, and comment are invited on the new
format. As for the retiring two-pager, appreci-
ation is expressed for letters, calls, and com-
ment— both kinds — over the past decade. —
R.B.K.

Mandatory Licensure
For Mississippi Nurses

The state medical association has a new pol-
icy on licensure of nurses, a carefully developed
course of action which is the product of open de-
bate, serious study, and multi-level review and
approval by constitutional bodies.

Subject to the actual bill introduced in the
1970 Regular Session of the Legislature as to
form and content, the association approves man-
datory licensure of nurses in Mississippi.

At the 101st Annual Session in May 1969.
the House heard sincere pro and con debate on
this issue. Recognizing it as a matter requiring
further study and mature consideration, the House
recommitted the issue to the Council on Medical
Service. The council, in turn, met and reviewed
the matter, assigning it to the Committee on Nurs-
ing. one of the council’s committees devoted to
one of its many specialized fields.

25

JANUARY 1970

EDITORIALS / Continued

The committee made studies, met with rep-
resentatives of the nurses association, took the
pulse of hospitals, and considered views of phy-
sicians. Through these deliberations, the new pol-
icy was carefully shaped with virtually no rami-
fication neglected in the process.

The committee first looked at licensure for
all health care and health-related professions.
Generally, such licensure is a function of the
states and has these characteristics:

— It is issued to an individual rather than to
a company, corporation, or impersonal entity.

— It authorizes the individual so licensed to
engage in a profession or occupation, usually
employing a special or distinctive identifying
title.

— It is granted on one or more of the follow-
ing conditions: Education or training minimums,
apprenticeship or practice, proficiency or knowl-
edge, good character, honorable intent, and at-
tainment of a stated age.

Licensure of an occupation or profession is
either mandatory or permissive. Of 13 health
care and health-related professions and occupa-
tions licensed in Mississippi, nine are mandatory
(as in the case of physicians and dentists), while
four are permissive. Mandatory licensure re-
quires that the individual practicing the profes-
sion or engaging in the occupation be licensed
and prohibits all others from doing so. Permis-
sive licensure permits only those licensed to use
a particular title or designation relating to the
profession or occupation, but others are not pro-
hibited from working in the field as long as they
do not use the protected title or designation.

Nurses have mandatory licensure in 42 state
jurisdictions for the R.N. and permissive licen-
sure in nine, including Mississippi.

Mississippi nurses have long sought manda-
tory licensure. Such a law was enacted in 1958
but vetoed by the then-Governor because of the
composition of the examining board and not, ac-
cording to the association’s understanding, be-
cause of the mandatory aspects. Arguments over
the issue have nearly always centered on the
crucial matter of whether such a law would ex-
acerbate the already serious shortage of nurses
in the state.

The draft bill which was examined by the as-
sociation's official bodies exempts from licen-
sure “any person functioning under proper su-
pervision as nursing aids, attendants, orderlies,
and other auxiliary workers in private homes,
offices, hospitals, nursing or rest homes, or insti-
tutions.”

The draft also omits the two physician-mem-
bers from the Board of Nurse Examiners. The
proposed board would consist of five R.N.’s and
two L.P.N.’s, and the latter would not be per-
mitted a vote except on matters relating to li-
censed practical nurses. The policy of the medi-
cal association expresses serious reservations over
the composition of the proposed board “not
necessarily related to the physician-members.”
The policy expresses concern for a “balance in
the exercise of this power by inclusion of health
team representatives other than nurses as full
voting members.”

But in giving approval to the principle of
mandatory licensure for nurses, the policy has
been carefully reviewed by a committee, an
elected council, and the Board of Trustees. It is
an expression of concern and good faith by the
physicians of Mississippi who have reserved the
right to speak up in the forging of any law which
may be enacted. — R.B.K.

Jackson Chamber Honors
Health Care Team

A very special year-end occasion honored
medicine in Mississippi as the Jackson Cham-
ber of Commerce made health care and care
providers the theme of its 1969 membership
meeting. Although the Jackson Chamber is typi-
cal in being oriented toward business and indus-

“Sorry we can’t discharge you from the hospital
today , Mr. Wilkins . . . it’s far too windy outside.”

26

JOURNAL MSM A

try, the capital city organization has strong med-
ical orientation, too.

The 3,000-plus member group has long recog-
nized that Jackson is a primary medical cen-
ter and has given strong support to develop-
ment of medical facilities in the capital. The
chamber points out with pride that medical care
is the second biggest “industry” in the city, sec-
ond only to state government in total employ-
ment. An estimated 8,000 individuals are in-
volved full time in health services and supportive
work.

The membership meeting, attended by 800 at
a gala banquet, singled out for recognition physi-
cians, dentists, hospitals, nursing homes, pharma-
cists, and health services supply sources. One
hundred twenty-five Jackson physicians are on
the active membership rolls of the chamber
which also boasts 33 dentists. Well represented
also are leaders from hospitals, nursing homes,
wholesale and retail drug firms, medical supply
sources, and dental laboratories.

Although the state feels the pinch of health
service personnel shortages, it benefits from a
continuing maximum effort by its health care
team. In turn, these providers of services are
grateful for recognition by civic leadership. Each
needs the other in working for a better state.
—R.B.K.

Our Environment
Is at Stake

If the fight against pollution is lost, then we
also lose the productive environment in a nation
of plenty. And the latest word is that we are los-
ing the fight.

The Comptroller General of the United States,
Elmer B. Staats, has reported to the Congress
that $5.4 billion — that’s $1.2 billion federal dol-
lars and a hefty $4.2 billion from the states —
spent on water pollution control has been largely
dissolved into the effluent and wastes that fill
our rivers, streams, and land-locked bodies of
water.

Mr. Staats says that some good has come of
the monumental effort, but pollution has increased
in spite of the expenditures. As waste control
projects are completed, more sources of pollution
crop up. In the 13 years of the life of the Federal
Water Pollution Control Administration, the ton-
nage of waste discharge into rivers and streams
has actually increased. Worse yet are the inade-
quate treatment systems which may mask the
problem.

The Comptroller General believes that pres-
ent programs are little more than a shotgun ap-
proach, and he hints that some funds have been
dumped into the pork barrel rather than the
sewage lagoon. There is also an overtone of in-
adequate state law and enforcement against mu-
nicipal and industrial pollution sources.

Mississippi was late coming into the program,
and we have a commission which is less than
two years old. But the important thing is that
something is being done about a serious health
and environmental safety problem. It’s not a
matter of shackling industry or of making produc-
tion uneconomical. Industry can no more survive
in a polluted environment than can its workers
and consumers of its products.

While Mr. Staats was addressing himself to
the economic aspects of the problem which is
his job in reporting to the Congress, he demon-
strated clearly that he understands the health
aspects of it, too. With stern realism, the report
recommends that no federal money be plunked
down for antipollution projects until their effec-
tiveness is assured.

All of this means that the task of creating a
safer environment is everybody’s job under well-
enforced laws. Pollution is a health problem of
undefined dimensions, but we can easily see that
it is massive enough to threaten our very existence.
We’d better do something about it — and soon.
—R.B.K.

January 19-23

CANCER CHEMOTHERAPY
INTENSIVE COURSE

University Medical Center, Jackson
January 19, 20, 21, 22, 23, 1970, beginning
at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Participants:

Warren N. Bell. M.D., professor of clinical lab-
oratory sciences and chairman of the depart-
ment and associate professor of medicine. The
University of Mississippi School of Medicine
G. D. Deraps. M.D., instructor in medicine. The
University of Mississippi School of Medicine

JANUARY 1970

27

POSTGRADUATE / Continued

This one-week intensive course will com-
bine lectures, group discussions, case presenta-
tions and actual clinical evaluation and man-
agement of patients with the most common
malignancies. Course content will include meth-
ods for office screening, tumor staging, natural
history of disease, indications and treatment
of various malignancies with chemotherapy
and radiotherapy.

February 9-13

RADIOLOGY INTENSIVE COURSE
University Medical Center, Jackson
February 9, 10, 11, 12, 13, 1970, beginning
at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Participant:

Robert D. Sloan, M.D., professor of radiology
and chairman of the department. The Uni-
versity of Mississippi School of Medicine

The one-week intensive course will include
practical observations of radiologic procedures
in the diagnostic, therapeutic, and isotope
areas, as well as sessions dealing with equip-
ment, techniques, artefacts, and radiation safe-
ty. Registrants will participate in numerous
diagnostic conferences demonstrating practical
points of radiographic interpretation, stressing
both the value and limitations of clinical radi-
ology.

Registration in both intensive courses is lim-
ited to five physicians from the class of 20 en-
rolled in the Mississippi Postgraduate Insti-
tute in the Medical Sciences, a Mississippi Re-
gional Medical Program-supported project de-
signed by the University of Mississippi Medi-
cal Center and the Mississippi State Medical
Association.

CIRCUIT COURSES

Southwestern Circuit

McComb — January 6 — Session 2, Southwest
Mississippi General Hospital, 7 p.m.
Session 2 — Hyperthyroidism

Medical Management, Dr. Herbert Lang-
ford

Surgical Management, Dr. Harvey Johns-
ton

Southern Circuit

Biloxi — January 7 — Session 1, Howard Me-
morial Hospital, 6:30 p.m.

Gulfport — February 4 — Session 2, Gulfport
Memorial Hospital, 6:30 p.m.
Hattiesburg — January 8 — Session 1; Febru-
ary 5 — Session 2, Forrest General Hos-
pital, 6:30 p.m.

Session 1 — Diagnosis and Management of
Anemia

In Adults, Dr. Guy Gillespie
In Children, Dr. Robert E. Carter
Session 2 — Diagnosis and Management of
Malignant Skin Lesions
Dermatologic Approach, Dr. James G.
Thompson

Surgical Approach, Dr. J. Manning Hud-
son

Eastern Circuit

Columbus — January 27 — Session 1, Lowndes
County General Hospital, 6:30 p.m.
Session 1 — Carcinoma of the Cervix

Radiologic Approach, Dr. Bernard Hick-
man

Surgical Approach, Dr. Richard Boronow
FUTURE CALENDAR

January 6, 1970

Circuit Course, McComb

January 7

Circuit Course, Biloxi
January 8

Circuit Course, Hattiesburg
January 19-23

Cancer Chemotherapy Intensive
Course

January 27

Circuit Course, Columbus
February 4

Circuit Course, Biloxi
February 5

Circuit Course, Hattiesburg
February 9-13

Radiology Intensive Course

February 11

Seminar on Back Pain

February 17

Circuit Course, Natchez
February 24

Circuit Course, Columbus

JOURNAL MSM A

March 2-6

Renal Disease Intensive Course
March 4

Circuit Course, Biloxi
March 6

Renal Disease Seminar
March 12

Circuit Course, Hattiesburg
March 16-20

Cardiology Intensive Course
Stroke Intensive Course

April 1-3

Cardiovascular Seminar
April 7

Circuit Course, McComb
April 16

Mississippi Thoracic Society, Jackson
April 21

Circuit Course, Columbus
May 11-14

Mississippi State Medical Association

RMP Awards
Cardiopulmonary Grant

The Mississippi Regional Medical Program has
awarded a nine-month grant of $38,988 to the
Mississippi Heart Association for a cardiopul-
monary resuscitation project.

Aimed at training members of the health team
in approved techniques of cardiopulmonary re-
suscitation, the program also seeks to broaden
the development of continuous inservice instruc-
tion programs in each regional hospital, nursing
home and extended care facility.

Erratum

Through an inadvertent binding error, pages
547-550 were omitted from some copies of the
December 1969 Journal, Vol. X, No. 12. The
missing pages are part of CPC XCV.

We apologize to our author. Dr. William B.
Wilson of Jackson, and to our readers. Those
having received copies with missing pages are
requested to inform the Editors by postal card,
and a complete reprint of the article will be re-
turned— with an unused postal card.

Cftest

HOSPITAL

(Formerly Hill Crest Sanitarium)

7000 5TH AVENUE SOUTH
Box 2896, Woodlawn Station
Birmingham, Alabama 35212

Phone: 205-836-7201

A patient centered
independent hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 44 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James A. Becton, M.D., F.A.P.A.

CLINICAL DIRECTORS:

James K. Ward, M.D., F.A.P.A.
Hardin M. Ritchey, M.D., F.A.P.A,

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

C/test

HOSPITAL

BIRMINGHAM, ALABAMA

JANUARY 1970

29

ORGANIZATION / Continued

Blair E. Batson and Janice Redd, both of
Jackson and UMC, attended the fall meetings of
the Southern Society for Pediatric Research in
Richmond, Va.

G. Lacey Biles of Sumner spoke at a recent
District Four Heart Association meeting in
Clarksdale. Also speaking was Walter Taylor
of Clarksdale who talked on diet and heart dis-
ease.

Robert E. Blount of Jackson and UMC met
with the American Rheumatism Association in
Tucson. Ariz. Dec. 5-6.

L. H. Bounds is serving his second term as pres-
ident of the Meridian Symphony Society Board.

John Bower of Jackson and UMC recently
spoke to the Corinth Chapter of the Kidney
Foundation of Mississippi about kidney disease
and the treatments including transplanting and
the artificial kidney machine.

Ralph H. Brock of McComb announces the re-
moval of his office to 150 Marion Avenue.

Raymond W. Browning of Greenwood an-
nounces the removal of his office to his newly
constructed clinic at 1317 River Road.

Paul B. Brumby of Lexington recently addressed
the annual convention of the Mississippi Fed-
eration of Licensed Practical Nurses, Inc. at
the Hotel Heidelberg in Jackson.

Ten Jackson physicians were cited as health
leaders by the Jackson Chamber of Commerce at
its annual meeting in November. Those spot-
lighted in the “Salute to Health Care Facilities
and People” were Robert Carter, David Wil-
son, James L. Royals, William O. Barnett,
James Hendrick, William Lotterhos, Alton
Cobb, W. L. Jaquith, Eric McVey, and Hugh
Cottrell.

Robert E. Carter, UMC dean and director,
participated in a National Volunteer Leadership
Conference of the National Foundation-March
of Dimes in San Diego in December.

Walter Crawford of Tylertown spoke to the

Tylertown Rotary Club during National Family
Health Week.

Robert L. Donald of Pascagoula has been
named State Chairman for Jaycee International
Medical Supplies Program. The J.I.M.S. Program
was conceived and initiated by Dr. Donald.

William E. Eggerton of Meridian announces
the opening of his offices at 1 1 2-24th Avenue
for the practice of dermatology.

Ira E. Gaddy, Jr. of Mississippi City has been
appointed to the board of trustees of Memorial
Hospital in Gulfport. Dr. Gaddy has the distinc-
tion of being the first physician appointed to the
board of trustees.

R. F. Gates of Gulfport has assumed the presi-
dency of the Coast Counties Medical Society.
New president-elect is Paul Horn of Biloxi and
retiring president is A. K. Martinolich of Bay
St. Louis. E. T. Riemann, Jr. of Gulfport was
named vice president, and Hal Cleveland of
Gulfport is secretary-treasurer.

Hannelore H. Giles of Hattiesburg announces
the opening of her office for the practice of cardi-
ology at 990 Hardy Street.

Raymond F. Grenfell and James L. Royals of
Jackson attended the AMA clinical meeting in
Denver last month.

Arthur C. Guyton, Harper K. Hellems,
Herbert G. Langford, Richard G. Hutch-
inson, Gaston Rodriguez, and David G. Wat-
son, all of Jackson and Joe M. Ross of Vicks-
burg attended the American Heart Association
scientific sessions and annual assembly in Dal-
las.

Carl Hale of Hattiesburg recently discussed
radiological services at Forrest General Hospital
at a Hub City Kiwanis Club meeting at the Red
Carpet Inn.

G. Swink Hicks of Natchez has been re-elected
to serve a three year term on the Board of Trus-
tees of the Mississippi Baptist Hospital.

Gerald Hopkins of Oxford recently spoke to
the District Six meeting of the Mississippi Heart
Association in Grenada. He was introduced by
Gaines L. Cook of Grenada, Medical Repre-
sentative of Grenada County.

Jerry W. Iles of Natchez presented a biograph-
ical summary of Dr. John Wesley Monette, the
first physician to become a member of the Mis-
sissippi Hall of Fame, at a recent meeting of

30

JOURNAL MSM A

ill

St

m

is

e

]

Achrocidin Tablets and Syrup

Tetracycline HC1— Antihistamine— Analgesic Compound

Each tablet contains: ACHROMYCIN® Tetracycline HC1 125 mg.; Phenacetin 120 mg.; Caffeine 30 mg.; Salicylamide 150 mg.; Chlorothen Citrate 25 mg.

ACHROCIDIN Tetracycline HC1— Antihistamine— Analgesic Compound Tablets and Syrup are recommended for the treatment
of tetracycline-sensitive bacterial infection which may complicate vasomotor rhinitis, sinusitis and other allergic diseases of the
upper respiratory tract, and for the concomitant symptomatic relief of headache and nasal congestion. For children and elderly
patients you may prefer caffeine-free ACHROCIDIN Syrup. Each 5 cc contains: ACHROMYCIN Tetracycline equivalent to
Tetracycline HC1 125 mg.; Phenacetin 120 mg.; Salicylamide 150 mg.; Ascorbic Acid (C) 25 mg.; Pyrilamine Maleate 15 mg.

Contraindications: Hypersensitivity to any
component.

Warning: In renal impairment, since liver tox-
icity is possible, lower doses are indicated; dur-
ing prolonged therapy consider serum level
determinations. Photodynamic reaction to sun-
light may occur in hypersensitive persons.
Photosensitive individuals should avoid expo-
sure; discontinue treatment if skin discomfort
occurs.

Precautions: Drowsiness, anorexia, slight gas-
tric distress can occur. In excessive drowsi-
ness, consider longer dosage intervals. Persons

on full dosage should not operate vehicles.
Nonsusceptible organisms may overgrow; treat
superinfection appropriately. Treat beta-
hemolytic streptococcal infections at least 10
days to help prevent rheumatic fever or acute
glomerulonephritis. Tetracycline may form a
stable calcium complex in bone-forming tissue
and may cause dental staining during tooth
development (last half of pregnancy, neonatal
period, infancy, early childhood).

Adverse Reactions: Gastrointestinal— anorexia,
nausea, vomiting, diarrhea, stomatitis, glossi-
tis, enterocolitis, pruritus ani. Skin— maculo-

papular and erythematous rashes; exfoliative
dermatitis; photosensitivity; onycholysis, nail
discoloration. Kidney— dose-related rise in
BUN. Hypersensitivity reactions— urticaria,
angioneurotic edema, anaphylaxis. Intracranial
—bulging fontanels in young infants. Teeth—
yellow-brown staining; enamel hypoplasia.
Blood— anemia, thrombocytopenic purpura,
neutropenia, eosinophilia. Liver— cholestasis at
high dosage.

Upon adverse reaction, stop medication and
treat appropriately.

LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 10965

534-9

PERSONALS / Continued

the Natchez Historical Society at Coyle House
on Wall Street.

William E. Lotterhos of Jackson addressed
the North Jackson Kiwanis Club in observance
of National Family Health Week. His topic was
the family physician today. Dr. Lotterhos is
president-elect of the American Academy of
General Practice.

Thomas Stanley Martin of Hattiesburg has
been elected to active membership in the Amer-
ican Academy of General Practice. Dr. Martin is
director of student health services and the medi-
cal clinic at the University of Southern Mis-
sissippi.

Albert Meena of Jackson has been elected as
one of nine directors of the Better Business Bu-
reau for a three year term.

Shelby W. Mitchell of Laurel is serving as
acting health director of Harrison County. The
post has been vacant since Hurricane Camille.
Dr. Mitchell’s regular assignment is health of-
ficer of Jones, Jasper, and Covington Counties.

Steven L. Moore of Jackson has been appoint-
ed Mississippi’s new comprehensive health plan-
ning director by Gov. John Bell Williams. Dr.
Moore was formerly director of the division of
local health services in the State Board of Health.

William G. Munn has moved into his new
medical clinic at the corner of East Jackson Ave-
nue and Oak Street in Mendenhall.

Dudley H. Mutziger of Natchez announces the
removal of his offices from 729 North Pearl Street
to the Medical Arts Building on Sgt. Prentiss
Drive.

Glenn T. Pearson of Hattiesburg has been
elected secretary-treasurer of the Hattiesburg
Area Chamber of Commerce.

Curtis D. Roberts of Brandon has been elected
vice-chief of the medical staff of Rankin Gen-
eral Hospital. Roland Samson was elected to a
three-year term on the executive committee, and
Robert Rester was named to the hospital’s ac-
tive staff.

Maurice Taquino of Biloxi was elected to the
board of directors of Harrison County Private
School Foundation at its annual meeting in Gulf-
port.

Norman W. Todd of Newton recently attended
an Air Medical Examiner Flight Surgeon Sem-
inar in Oklahoma City. Dr. Todd has been a sen-

3 2

ior medical examiner for all types of commercial
and private pilots for 10 years.

Richmond Sharbrough of Vicksburg has been
elected vice president of the newly organized
Men’s Golf Association of that city.

Guy T. Vise of Meridian is serving as chairman
of the Operation Drug Alert committee of the
Meridian Kiwanis Club. The program is de-
signed to alert Meridian people to the dangers
of drug abuse.

David G. Watson of Jackson participated in a
symposium on the Natural History and Progress
in Treatment of Congenital Heart Disease Dec.
3-7 in Toronto, Canada.

David B. Wilson of Jackson and UMC attended
the Washington, D. C. meeting for a Maryland-
D. C.-Delaware Hospital last month.

. Armstrong, George Glaucus, Sr., Hous-
ton. M.D., Memphis Hospital Medical Col-
lege, Tenn., 1903; residency, Charity Hospital,
Jackson, Sept. 1, 1918-Dec. 1, 1919; postgradu-
ate work, Chicago EENT College, Illinois, 1920
and 1922; EENT Hospital, New Orleans, La.,
1925 and 1927; member MSMA Fifty Year Club;
Emeritus member MSMA and AMA: died Nov.
17, 1969, age 90.

Otken, Luther B., Sr., Greenwood. M.D.,
University of Texas Medical Branch, Galveston,
1917; interned Manhattan Maternity Hospital,
New York City, N. Y., one year; died Nov. 25,
1969, age 80.

Raney, Daniel H., Mattson. M.D., Uni-
versity of Texas Medical Branch, Galves-
ton, 1917; interned St. Louis City Hospital, 3
months; scholarship Edinburgh, Scotland, 1919;
member MSMA Fifty Year Club; Emeritus mem-
ber MSMA and AMA; died Nov. 27, 1969, age
82.

No reports of election of new members in the
association were reported to the Journal during
December 1969.

JOURNAL MSMA

Book Reviews

Genetics and Counseling in Medical Practice.
By Leonard E. Reisman, M.D. and Adam P.
Matheny, Jr., Ph.D. 215 pages with illustrations.
St. Louis: The C. V. Mosby Co., 1969. $12.75

This small volume provides a good overall
view of genetic counseling aimed at the medical
practitioner. It is easy to read, and well worth
reading for anyone called on to provide counsel-
ing for genetic disorders. Its greatest value is as
a volume to read through for “the big picture”
since it is not an exhaustive reference text. It
nevertheless presents adequately the fundamen-
tals of the major areas of medical genetics in-
cluding probabilities, Mendelian principles, chro-
mosome abnormalities and inborn errors.

Chapters on the general approach to genetic
counseling, genetics and cancer, and mental re-
tardation are particularly commendable. These
chapters answer frequently-recurring questions
directed by the medical practitioner to the genetic
counselor. The authors have obviously drawn a
great deal of the material from their own experi-
ences in the sections on chromosome abnormali-
ties and their clinical photographs are very good.

Diagrammatic illustrations explaining inherit-
ance patterns are lacking, and the explanations
in text, though adequate, may thus be hard to
find for quick review by a busy practitioner.
The authors have perpetuated the inadequate
nationwide list of service facilities for genetic
counseling which would be better omitted in fa-
vor of a reference to the International Directory
of Genetic Services edited by Bergsma and
Lynch and published by the National Founda-
tion.

John F. Jackson, M.D.

Symposium on Sports Medicine. By the Amer-
ican Academy of Orthopaedic Surgeons. 210
pages with 199 illustrations. St. Louis: The C. V.
Mosby Company, 1969. $15.00.

In 1962 the Executive Committee of the
American Academy of Orthopaedic Surgeons
established a Committee on Sports Medicine up-

on the recommendation of President-Elect Dr.
Clinton Compere. This Committee was charged
with many approaches to improving the medi-
cal care, and particularly the orthopaedic care of
American youth engaged in athletics. Dr. Don
O’Donoghue was appointed chairman. A major
mandate was to develop a sophisticated post-
graduate course on sports medicine for ortho-
paedic surgeons and other physicians with a spe-
cial interest in the care of the athlete. At this
postgraduate course approximately twenty very
fine papers were presented and appropriately, the
papers presented at this course have now been
compiled as a birthday volume to Dr. O'Don-
oghue.

The essayist of each of the individual papers
is an expert in his field and all have a definite in-
terest and insight into the problems of treating
sports injuries. The articles are varied in their
topics and include problems of evaluation of
perspective athletes, as well as detailed reports
of the effect of altitude on the athletes during
the most recent Olympic games. All of the ex-
tremities with reference to the most frequent in-
juries are well covered and I feel that the six
separate papers dealing with knee injuries are
the best that 1 have seen.

This book would definitely be of benefit as a
reference for any physician who is dealing with
athletic injuries, whether he be an orthopaedic
specialist or not. There are one hundred ninety-
nine illustrations, which are all very well done
and very clearly produced on paper.

I feel that the Committee on Sports Medicine
of the American Academy of Orthopaedic Sur-
geons should be commended on this publication
and recommend it highly to any physician deal-
ing with these problems.

H. Lowry Rush, Jr., M.D.

New Books Received

The Practice of Refraction. By Sir Stewart
Duke-Elder, M.D., Ph.D., F.A.C.S. 321 pages
with 244 illustrations. St. Louis: The C. V.
Mosby Company, 1969. $11.75.

JANUARY 1 970

35

THE LITERATURE / Continued

Acute Renal Failure: Diagnosis and Manage-
ment. By Robert G. Muehrcke, M.D., F.A.C.P.
263 pages with 126 illustrations. St. Louis: The
C. V. Mosby Company, 1969. $19.75.

Health Education. By Bernice R. Moss, Ed.D.,
Warren H. Southworth, Dr. P.H., and John Les-
ter Reichart, M.D. Washington, D. C.: National
Education Association of the United States, 1969.
Fifth Edition. $5.00.

Cardiac Arrest and Resuscitation. By Hugh
E. Stephenson, Jr., M.D.. F.A.C.S. 500 pages
with 223 illustrations. St. Louis: The C. V. Mos-
by Company, 1969. $29.50.

Handbook of Ocular Therapeutics and Phar-
macology. By Philip P. Ellis, M.D., and Donn
L. Smith, M.D. and Ph.D. St. Louis: The C. V.
Mosby Company, 1969. Third Edition. $10.75.

Fundamentals of Inhalation Therapy. By Don-
ald F. Egan, M.D. 468 pages with 148 illustra-
tions. St. Louis: The C. V. Mosby Company,
1969. $11.00.

Arrows of Mercy. By Philip Smith. 236 pages.
Garden City N. Y. : Doubleday and Company,
1969. $5.95.

FDA Warns Against
Bard Urethral Catheters

The Food and Drug Administration has issued
a warning to all physicians and clinics against
using 49 types of urethral catheter trays and
kits produced by C. R. Bard, Inc., of Murray
Hill. N. J.

All of these trays contain a packet of cleans-
ing solution or “detergicide.” This detergi-
cide,” also called “prep solution,” “cleansing so-
lution,” or “antiseptic towlette,” has been found
to contain bacteria of pseudomonas species, com-
monly known as EO-1, a pathogenic organism
which may produce severe genitourinary infec-
tions.

C. R. Bard, Inc., undertook a voluntary recall
in Sept, of the contaminated trays from its dis-
tributors and from hospitals in the United States
and Canada. FDA has determined that the re-
call was not effective due in part to lack of co-
operation by several large distributors who de-
clined to participate.

FDA attempted to warn nursing homes and
the medical profession of the dangers involved
in the use of these trays by issuing a press re-
lease in Oct.

Administration checks on dissemination of the
warning revealed, however, that the majority of
nursing and convalescent homes are still unaware
of the recall or the health hazards of the cath-
eter trays containing the contaminated detergi-
cide. They are still in use in many institutions.

Recently a marked increase in severe genito-
urinary infections associated with the use of the
catheter trays containing the contaminated agent
has been reported by hospital authorities.

Additional investigations by the FDA have
also disclosed non-sterility of some of the lubri-
cant jelly packs in the Bard trays. Both FDA and
AMA are attempting to alert all physicians as-
sociated with hospitals, urologic clinics, nursing
and convalescent homes, to take immediate steps
to check all stocks of sterile urethral catheter
trays or kits from C. R. Bard, Inc. They should
arrange for prompt return to the supplier of any
existing stocks bearing any of the following re-
order or item numbers:

7501, 7503, 7505, 7602, 7602P, 7604,
7610, 8145, 8214, 8216, 8218, 8220, 8300,
8364-16, 8364-18, 8365-16, 8365-18, 8400,
8401, 8464-16, 8464-18, 8464D-16, 8464D-
18, 8465-16. 8465-18, 8500, 8501, 8504-16,
8504-18, 8505-16, 8505-18, 8505A-16,

8505A-18, 8554, 8556, 8554-A, 8556-A,
8558, 8558-A, 8560, 8810, 8816, 8816-A,
8818, 8818-A, 8819, 4200, 4210, 8556-A,

8 5 60- A.

Frontiers of Medicine
1970 Scheduled

Registrations are being accepted for Frontiers
of Medicine 1970 to be held in Lakeland, Flor-
ida, Feb. 18 through 20. The meeting, sponsored
by the Lakeland Graduate Medical Assembly,
has been approved by the American Academy
of General Practice for 14 hours elective credit.

A wide range of current medical topics is of-
fered by this year’s Frontiers of Medicine pro-
gram with an outstanding guest faculty from
throughout the United States.

Co-sponsors of the Frontiers meeting — which
last year was highlighted by Drs. Christiaan
Barnard and Denton Cooley — are the medical
staffs of Winter Haven Hospital and Bartow
Memorial Hospital.

Registration fee is $100. For details, contact
the Lakeland Graduate Medical Assembly, P. O.
Box 23335, Lakeland, Florida 33830 (813/
683-1636 or 683-2038).

36

JOURNAL MSMA

USM Student Health Services Offers
Comprehensive Campus Care Program

One of the more important buildings at the
University of Southern Mississippi in Hattiesburg
is a modest two-story brick and tile structure on
the main campus, nestled between a cluster of
more imposing “cousins.”

The unit is the USM Infirmary, where despite
a relatively limited floor space as compared to
dormitory and classroom buildings, an astound-
ing number of students trek annually through
its doors.

Constructed in 1962, the unit replaced an
outdated wooden building which had long since

Though small in size, in contrast to towering
Pulley Hall at right , the University of Southern Mis-
sissippi’s Health Services Clinic is a busy place,
sometimes treating more than 6,000 out-patients a
quarter. Only a portion of the two-story, 36-bed in-
firmary is visible here. Dr. Thomas S. Martin, M.D.
is Director of Health Services at USM.

seen its best days. The present infirmary has
about 10,000 square feet of assignable area, 36
beds, and all of the necessary rooms for the ser-
vices offered.

Dr. Thomas S. Martin is director of Student
Health Services, and is now entering his fourth
year with the school. Dr. Martin serves also as
team physician, and as assistant professor of
health and physical education, teaches some
classes.

The staff at the infirmary consists of Dr.
Martin and seven registered nurses, who rotate
hours according to work load levels, so as to pro-
vide 24-hour service. For a time a second phy-
sician was available full-time. However Dr. Andin
C. McLeod, Jr. has now left in order to obtain
further specialized training.

The Student Health Services is supported by
a health fee which is included in an incidental
fee. Broadly it covers clinical and hospital ser-
vices limited to cases of ordinary illness. The
University does not assume responsibility in cases
of extended illness or for treatment of chronic
diseases. Cases requiring surgery are handled by
a physician and hospital of the student’s choice.

After initial evaluation and possible treatment,
the USM infirmary may make further disposi-
tion of the patient, including continued treat-
ment of minor illnesses either as a bed patient or
as an ambulatory out-patient; referral to a local
private physician or clinic for further diagnostic
evaluation and treatment if the case is other than
a routine minor illness; send the patient home to
the care of his local physician if the condition war-
rants, and especially if the expected duration of
illness is lengthy; or requires hospitalization.

The School Health Service attempts to moni-
tor and maintain surveillance over the student’s

JANUARY 1970

3 7

ORGANIZATION / Continued

general health, while he is away from home, and
to offer liaison between his own family physi-
cian, his parents, and/or his local physician.

Types of illness most frequently encountered,
and their disposition, include:

The various types of tonsilopharyngitis are the
most common illnesses seen. Where the duration
is short, they are treated at the infirmary, but
where a period of several weeks is anticipated,
the cases are sent home for treatment by the
family physician. Since it is important to identify
and separate the cases of streptococcus bacterial
sore throats so that they may be adequately
treated in order to prevent rheumatic fever, a
throat culture is taken in most cases, done by
the State Board of Health at no charge.

Sprains and strains during intramural seasons
and late afternoon activities produce many mus-
culoskeletal injuries that are treated at the school.
The nurses are well-trained in physical therapy
measures. An ice machine and a whirlpool bath
have proven invaluable. Other orthopedic prob-
lems are generally referred to local orthopedic
surgeons, of which there are now four in Hatties-
burg.

Lacerations that occur on campus as a result
of accidents, intramurals, or athletics are surgi-
cally repaired in the clinic. Those resulting from
automobile accidents and off-campus incidents
are referred to the Forrest General Hospital
emergency room. Though not deemed the respon-
sibility of the school, the school physician is
usually called upon by the hospital to care for
these patients in the emergency room, the stu-
dent bearing the cost.

Respiratory problems, most being of viral
origin, are amenable to bed rest, anti-pyretics,
and expectorants. More severe cases are often
referred to the care of a local or home-town
physician. X-rays are sometimes required, at the
student’s expense, and are made at the Forrest
General Hospital.

Bacterial pneumonia is generally not consid-
ered a minor illness, but is sometimes treated
on-campus, out of necessity or special conveni-
ence to the patient.

Viral influenza does not lend itself to adequate
treatment on the campus and victims are too ill
to attend class. Because of this and the usual
long duration, victims are sent home, as a rule,
where there is a better chance for a more rapid
recovery. In September, preventive “flu-shots”
are offered — but the protection rate is only about

30 per cent and only a relatively few students
and faculty avail themselves of the vaccine.

Gastrointestinal problems constitute the sec-
ond most frequent complaint on campus, embrac-
ing the syndrome of nausea, vomiting, and diar-
rhea. Some of these illnesses are food-borne in
origin, while most are the result of viral infection.
Generally, an overnight stay in the clinic with
proper supportive measures is adequate for re-
covery. Acute abdominal emergencies are re-
ferred elsewhere.

The clinic is equipped to handle acute asth-
matic attacks, and other emergency situations
due to allergies. Allergy injections, prescribed
by private physicians, are administered by the
nursing staff according to directions given by the
student’s physician.

Emotional problems embracing acute hysteria,
very mild depression, or anxiety cases fall in the
category of minor illnesses, but more severe cases
are referred elsewhere. Under the direction of a
psychiatrist a student may be observed for
several days in the clinic, when requested by his
physician.

Genitourinary problems include cystitis, usual-
ly treated at the clinic and followed up with re-
ferral to specialists when required; and kidney
trauma, with the clinic used in precautionary ob-
servation, thus saving the student a large hos-
pital bill.

The USM Clinic operates around the clock
during each school quarter. Two scheduled clin-
ics are held daily, one in the morning, the other
in late afternoon. The late “sick call” draws the
most patients. A daily clinic load for the physi-
cian may consist of as few as 35 patients to a
peak of 124.

The clinic operation provides most of the
commonly used drugs to the student body free of
charge. They often issue drugs such as antihista-
mines, antibiotics, and antipyretics. Many pre-
scriptions must still be written however and filled
by area drug stores at student cost.

A universal problem for student health ser-
vices is kept under moderate control at USM.
Written excuses to class instructors for class ab-
sences are not provided. At an institution of
nearly 8,000 students, this has eliminated the
unending lines of “written-excuse-seekers.” How-
ever the student is encouraged to explain his
problems to the instructors, and verification of
clinic visits via telephone is always available if
the instructor calls.

An indication of the patient load experienced
over a period of time at USM is the fact that

38

JOURNAL MSMA

4.576 out-patients were treated during spring
quarter as compared to 6.220 during winter
quarter, 1969. During the same periods, 282 bed
patients were provided for in spring quarter, and
387 during winter quarter.

Presently Southern is seeking another full time
physician. “We hope to attract another man of
Dr. Martin’s caliber,” Dean Peter E. Durkee
comments. Any inquiries from interested physi-
cians should be directed to Dr. Durkee, Dean of
Student Affairs, Box 7, Southern Station, Hat-
tiesburg. Miss. 39401.

MSU Mitchell Lectures
Features Dr. Cooper

The C. B. Mitchell Lectures of Mississippi
State University this year featured Dr. Louis Z.
Cooper, one of the nation’s leading researchers
on the Rubella or “German Measles” problem.

The second distinguished lecturer in the MSU
series, Dr. Cooper is author of “Rubella: A Pre-
ventable Cause of Birth Defects.” He received his
M.D. degree from Yale University School of Med-
icine and is currently affiliated with the New
York University Medical Center and Bellevue
Hospital.

While on campus Dr. Cooper spoke to pre-
med students about challenges in the fields of
career research, internal medicine, and pedi-
atrics. On Mon., Dec. 8, he conducted an exten-
sive testing of several thousand young women of
child-bearing age to determine their suscepti-
bility to Rubella.

Rubella, more commonly known as German or
Three Day Measles, accounts for birth defects
in hundreds of children each year. This year a
“giant leap” in medicine was the production of
an effective vaccine for Rubella along with a
simple new technique for determining individual
susceptibility (or immunity) to this previously
wide-spread “childhood” disease.

The initial use of the vaccine is to go to all
children who are primarily responsible for the
epidemic spread of Rubella and the exposure to
susceptible mothers-to-be. Prospective mothers
should then be tested for immunity. Dr. Cooper
says, “The concept is to vaccinate children to
protect the mothers.”

The test for immunity consists of a drop of
blood on a piece of filter paper. This properly

identified specimen processed in Dr. Cooper’s
laboratory can determine if the patient has ever
had Rubella. He estimates that there are 2,000,-
000 women of child-bearing age in this country
who are susceptible.

The C. B. Mitchell Lectures initiated last year
was tremendously successful with the two days
and nights of appearances of the world known
authority on the health hazards of tobacco, Dr.
Alton Ochsner of New Orleans.

The C. B. Mitchell Pre-Med Fund was estab-
lished in 1967 by Mississippi State University
Medical Alumni and friends in recognition of
the need for an enriched premedical curriculum
at Mississippi State and in honor of the doctor
who served MSU students for so many years as
college physician.

The program was supported in part by the
Merck Sharp and Dohme Post-Graduate Medi-
cal Program and the Oktibbeha County March
of Dimes.

Self-Employed M.D.’s
Insured for Disability

Many self-employed physicians reached an im-
portant social security landmark this October.
With their earnings covered since 1965, they
have now contributed to social security long
enough to be insured for disability.

Social security disability benefits can be paid
to an insured person under 65 who has a physi-
cal or mental impairment so severe as to keep
him from doing any substantial work for a year
or longer. Payments begin after a waiting period
of 6 full calendar months.

Benefits can be as much as $218 a month for
a disabled person alone and up to $434.40 a
month for a family. Self-employed physicians dis-
abled in the immediate future, however, would
probably not yet be eligible for these maximums
since their earnings have been covered by social
security for a relatively short time. Benefits are
figured from a person’s average covered earnings
over a period of years.

“This disability protection can be a valuable
supplement to the physician’s private insurance,”
said Bernard Popick. director of social security’s
disability program. “It is part of the total social
security package of protection — disability, re-
tirement, survivors and health insurance — toward
which the physician has been contributing.”

JANUARY 1970

39

ORGANIZATION / Continued

AMA’s Dr. McCleave Is
MSMA and UMC Guest

As part of the continuing program of the
MSMA Committee on Medicine and Religion,
The Rev. Dr. Paul D. McCleave, director of the
AMA department of medicine and religion, met
with the state committee and appeared before
the student assembly at the University Medical
Center in late November.

In his remarks to the committee and the stu-
dents, Dr. McCleave addressed himself to the
care of the whole man and to problems in pa-
tient care related both to physical aspects and to
moral issues confronting both patients and phy-
sicians.

Dr. John M. Alford, Jr. of Greenwood, chair-
man, presided at the MSMA committee meeting.
John Sanders, president of the junior class at
UMC and chairman of the student assembly
committee, served as host to Dr, McCleave. Also
appearing on the program was Thad Waites of
Waynesboro, student body president.

At the state association meeting, members of
the UMC student government as well as Dr.
Robert E. Carter, medical school dean and di-
rector, were present as guests of the committee.

The Committee on Medicine and Religion is
a constitutional body of the association whose
members are Drs. Andrew K. Martinolich, Jr.,
of Bay St. Louis, F. C. Minkler, Jr., of Pasca-
goula, S. Lamar Bailey of Kosciusko, Eugene M.
Murphey, III, of Tupelo, Julian Wiener of Jack-
son, and Dr. Alford, chairman.

Highlighting the MSMA Committee on Medicine
and Religion meeting at which Dr. Paul McCleave,
second from right , director of the AMA department
of medicine and religion, appeared was a private
luncheon at Primos' Northgate Restaurants. Discuss-

ing Dr. McCleave’s address are from left, Dr. Rob-
ert Carter, UMC director and dean; Dr. John Alford,
MSMA committee chairman; and John Sanders,
chairman of the medical center student assembly
committee.

40

JOURNAL MSMA

Regional Medical
Expands Activities

Out of the planning and into the doing phase
as of July 1, the Mississippi Regional Medical
Program has mounted seven new projects and is
set to expand two established activities with a
$1,527,930 grant for 1969-70.

The award from the Division of Regional Med-
ical Programs, Health Services and Mental Health
Administration, DHEW, also covers cost of de-
veloping additional projects to improve the qual-
ity and availability of diagnosis and treatment of
heart disease, cancer, stroke, and related dis-
eases in Mississippi.

Says Dr. Guy Campbell, Mississippi coordi-
nator, the seven new projects are pieces of an
over-all plan to provide more health manpower,
and improve the health service delivery system
by Unking to available resources such as the
State Board of Health, Office of Comprehensive
Health Planning, and the University Medical Cen-
ter.

Emphasis thus far is on continuing education
and on clinic expansion, he says. New programs
are:

Mississippi Postgraduate Institute in the Medi-
cal Sciences, described elsewhere in this publi-
cation, with the Mississippi State Medical As-
sociation and University Medical Center as co-
applicants.

Recruitment of Health Manpower in Mississip-
pi— a Mississippi Hospital Association program
to stimulate student interest in health careers and
initiation of now nonexistent allied health train-
ing programs.

Cardiovascular Clinics — The State Board of
Health plan to strengthen its heart clinic network
with the cooperation of local physicians, the Med-
ical Center and the Mississippi Heart Association.

A System of Coronary Care Units in Mississip-
pi— a University Medical Center project to estab-
lish an exemplary coronary care unit in the
teaching hospital as the first step in a system of
regional centers which may monitor individual
beds in smaller hospitals in the area.

Therapy Training and Consultation Program
— The Medical Center’s project to begin correc-
tion of deficiencies in personnel, facilities, and
educational opportunities in radiation therapy so
the service can be expanded and upgraded
throughout the state. The first year’s budget will
finance purchase of a linear accelerator.

Regional Comprehensive Neurology Clinics —
The State Board of Health and Medical Center

joint plan for clinics in six cities to cover all neuro-
logical disease with emphasis on stroke and with
input from a primary and a rehabilitation team,
and correlation with the heart clinics and the
demonstration stroke unit at University.

Comprehensive Renal Disease Training Pro-
gram— A Medical Center application to carry out
training programs for physicians, nurses, and
others who care for nephrology patients, includ-
ing those on chronic dialysis.

Three-year funding was approved for five of
the seven projects.

The grant also covers renovation funds for the
pulmonary disease training program initiated as a
feasibility study under earmarked money last
March.

Support also continues for the four-bed Dem-
onstration Stroke Unit which is to expand to six
beds with the renovation of the vacated seventh
floor nursing unit to be shared with the Clinical
Research Center.

In approving the Mississippi program for op-
erational activities, the national reviewing bodies
noted the involvement of major health organiza-
tions such as the Mississippi State Medical As-
sociation in the planning process, the close tie-
in with the Office of Comprehensive Health Plan-
ning, and cordial relationship with adjoining re-
gions. Mississippi’s avowed intent to do first what
can be done with existing resources and the re-
gion’s recognition of its health manpower as its
key asset were seen as strengths in an early pro-
gression from planning to activation.

Florida Hosts PG
Education Program

The Department of Psychiatry of the Univer-
sity of Florida College of Medicine and the north-
east, central and southwest chapters of the Flor-
ida Psychiatric Society will co-sponsor a pro-
gram of continuing education in Gainesville,
Florida on Feb. 10-11, 1970. The program will
consist of lectures and workshops and will fea-
ture Dr. Harold Rosen of Johns Hopkins Uni-
versity of ‘‘Psychiatry and the Abortion Faws”
and “Hypnosis in Psychiatry.” Dr. Samuel R.
Warson of the department of psychiatry is di-
rector of the workshop.

For programs and reservations requests should
be directed to the Division of Postgraduate Edu-
cation. J. Hillis Miller Health Center, Box 758,
University of Florida, Gainesville, Florida 32601,
Tel. 904-392-3143. A general announcement bro-
chure will be distributed about Dec. 15.

JANUARY 1970

41

ORGANIZATION / Continued

UMC and MSBH Set
Up Neurological Clinics

Two state agencies have pooled resources to
put a new medical team in the field conducting
clinics for victims of neurological diseases and
related disorders.

Working together on the team are the State
Board of Health, through its Division of General
Health Services, and the University of Mississippi
Medical Center in Jackson.

The effort is officially titled the Regional Com-
prehensive Neurology Clinics project and is made
possible under a grant from the Mississippi Re-
gional Medical Program.

The team includes neurologists and resident
physicians from the Medical Center, and a social
worker, and it is supplemented at each clinic by
State Board of Health nurses.

It conducts clinics on the third Monday and
Tuesday of each month, spending one full day
in each of six selected municipalities over a
three-month period.

Two clinics are held in the State Board of
Health county health department facilities in
Meridian, Hattiesburg, Pascagoula, Gulfport,
Cleveland and Indianola.

Dr. Frank M. Wiygul, Jr., director of the
Division of General Health Services, State Board
of Health, estimates that at least 1,000 patients
will be seen through this new project over a one-
year period.

He estimates 35 patients can be seen each
clinic day, or 70 patients a month, for a total of
840 patients a year at the clinics, with another
160 referred from the clinics to the medical cen-
ter.

Theoda Griffith and Terry Beck, working with
Dr. Wiygul in the General Health Services Di-
vision in setting up the clinic schedules, say the
estimate may be on the conservative side.

“In addition to the medical team,” says Dr.
Wiygul, “we have plans for a follow-up team,
including an electroencephalogram technician, a
physical therapist and a speech therapist.

“Patients with strokes and other neurological
conditions which need more medical attention
will be referred to University Hospital for admis-
sion either to neurological service or to the
stroke center.”

The aim of the project, says Dr. Wiygul, is to
provide neurological consultation for patients out-

side of the central-Mississippi area which has
comparatively easy access to facilities in Jack-
son.

“We want to provide improved diagnostic ca-
pability and over-all neurological care through
laboratory procedures which are not routinely
available elsewhere in the state,” Dr. Wiygul
adds.

“The project also should develop referral re-
sources for physicians in private practice, and it
will develop community awareness of the special
services needed by those with neurological dis-
eases.

“We also will provide neurological consultant
services to other health-related programs and
orient existing health-resources agencies toward
more comprehensive stroke evaluation and care.”

He said there is a possibility of expanding the
project to the state’s northermost counties through
a related project grant utilizing the University
of Tennessee Medical School in Memphis.

The project now under way was approved for
three years with the first year’s grant approxi-
mately $60,000.

Dr. Wiygul pointed out that the current proj-
ect is an outgrowth of an earlier epilepsy project
which lasted five years with which he was associ-
ated, and which was restricted to children.

Court Gives Upjohn
Right to Argue

The U. S. Court of Appeals in Cincinnati.
Ohio, has told The Upjohn Company that in
December the court would hear oral argument on
legal action by the company to prevent the Fed-
eral Food and Drug Administration from en-
forcing its order of Sept. 19, which would remove
seven of the company’s combination antibiotic
products from the market.

The court noted that the Food and Drug Ad-
ministration had voluntarily agreed to suspend
action against the products pending a decision
by the court.

At the December hearing the court will hear
argument on why the Sept. 19 order is illegal in
seeking to remove the products from the market.

“The products like Panalba have been used
widely and successfully for many years,” R. T.
Parfet, Jr., president and general manager of
Upjohn, said. “We believe the FDA is in er-
ror in its attempt to remove them from the mar-
ket and that the FDA action is unjustified.”

42

JOURNAL MSM A

Rubella Campaign
Gets Good Results

State Board of Health officials report a satis-
factory response thus far to a long-range Rubella
immunization campaign concentrating on five-
year-olds and six-year-olds.

“We don’t have enough vaccine to go into all
82 counties at once,” said Paul M. Turner, Jr.,
state coordinator for the Vaccination Assistance
Program of the State Board of Health.

He said county-wide campaigns already have
been carried out in Lamar and Perry counties,
with some 70 per cent of the first-grade and
second-grade children immunized in those two
counties.

He said additional campaigns are already
planned for Quitman, Benton, Claiborne, Copiah
and Hinds counties and others will be announc-
ing from day-to-day as “local health departments
tool up to give the immunizations.”

“As the vaccine becomes more readily avail-
able,” said Turner, “other health departments
will make plans for clinics” in their local schools
and Head Start centers. He added:

“State Board of Health technicians will go
into these counties at the request of the local
health departments, as each county takes on the
responsibility of immunizing their children.”

Turner said the State Board of Health will soon
release single-dose and ten-dose vials of Rubella
vaccine to all 82 counties for routine use.

He pointed out at that time that the cam-
paign is an “open-end” proposition, without dead-
lines, since reaching all five-year-old and six-
year-old children in the state will take time.

He also noted that reaching this age group is
only the first phase of the total plan, which
eventually will reach children up to age 1 1 .

“We’re talking about a ten-year span of age
categories,” he said, “with more children coming
on each year. That means at least 500.000 chil-
dren. We estimate that the State Board of Health
would immunize half, and private physicians
half, so we’re talking about 250,000 children."

Dr. Blakey said the program might take three
years and calls for a “massive effort” concen-
trated both in time and in a sequence of priority
age-groups.

He said Rubella “is one of the major known
causes of congenital defects, such as heart disease,
blindness and deafness,” and five-year-olds and
six-year-olds are the most susceptible age groups.

Allergy Academy
Announces PG Course

The American Academy of Allergy has an-
nounced the program for a postgraduate course
to be held Feb. 14-15, 1970, in the Jung Hotel,
New Orleans, La.

Major topics to be covered include pulmonary
diseases and asthma, developments in medicine
relating to allergy, clinical immunology, and or-
gan transplantation.

Featured speakers are Dr. Gustave A. Lau-
renzi. St. Vincent Hospital of Worcester, Mass.;
Professor Jack Pepys, Institute of Diseases of
the Chest of London; Dr. Eugene Robbins, Uni-
versity of Pittsburgh, Pa.; Dr. Charles R. Park of
Vanderbilt University; Drs. Thomas C. Merigan
and Keith B. Taylor of Stanford University.

Other lecturers include: Dr. Fred Rosen of
Harvard; Ray D. Owen, Ph.D., California Insti-
tute of Technology at Pasadena; R. E. Billing-
ham, D.Sc., University of Pennsylvania at Phila-
delphia; and Dr. David Hume, Medical Col-
lege of Virginia at Richmond.

Miss. Med. Assistant
Named AAMA Trustee

Mrs. Thomas D. Pace, Jr., Mississippi’s first
certified medical assistant, was named trustee of
the American Association of Medical Assistants
at their 13th annual convention in Honolulu.

Mrs. Pace, who lives at 4545 Meadow Hill
Drive, is administrative assistant to Dr. Myra
Tyler at the University of Mississippi Medical
Center.

She also was appointed as chairman of the
AAMA junior college coordination committee, by
the AAMA executive committee.

Mrs. Pace is president of the Mississippi Asso-
ciation of Medical Assistants, vice president of the
Jackson Symphony League and chairman of the
Mississippi Art Association.

Featured speakers at the Honolulu convention
included AMA President Gerald D. Dorman of
New York and Dr. Christiaan N. Barnard of
Johannesburg, Union of South Africa.

AAMA's 1970 convention will be held in Des
Moines, Iowa.

JANUARY 1970

4 3

(

Medical Response to
Camille Evaluated

An evaluation of the medical response to Hur-
ricane Camille is under way following a disaster-
evaluation planning conference in Gulfport.

Dr. Henry C. Huntley, Washington, D. C.,
chief of the Emergency Health Service division
of H.E.W., flew to the coast to look at the disaster
area and to attend the conference.

Afterwards, he said he will send interviewers
from his office within the next week or so to pre-
pare a comprehensive report on health services
rendered in the wake of the hurricane.

“This disaster,” said Dr. Huntley, “affected
more people to a greater extent — in a concen-
trated population area — than any other in the
United States in modern times.

“I’ve seen many disasters, but I’ve never seen
the destruction and the number of people af-
fected as I have here. I'm very impressed by the
response of the community and the state.”

Dr. H. B. Cottrell, state health officer, Missis-
sippi State Board of Health, cited “splendid co-
operation between the medical community and
the State Board of Health” in coping with the
disaster.

He said follow-up work related to health ser-
vices “will take weeks — maybe months,” espe-
cially as regards environmental health — a re-
sponsibility of the State Board of Health’s Di-
vision of Sanitary Engineering.

Dr. Cottrell pointed to the need of continuous,
long-range “collaboration and joint planning” by
all health agencies and the related organizations
at all levels involved in disaster work.

The Mississippi State Medical Association was
represented at the high-level critique by Dr. C. D.
Taylor, chief of the medical staff of Gulf-
port Memorial Hospital, where the meeting was
held.

Representing the Mississippi Hospital Associ-
ation were Richard H. Malone, president of
Hinds General Hospital in Jackson and presi-
dent of the M.H.A., and Charles W. Flynn, Jack-
son, M.H.A. executive director.

Also in attendance were administrative person-
nel of coast-area hospitals, Keesler Air Force
Base U.S.A.F. Medical Center, the Veterans
Administration Center at Biloxi, and the State
Board of Health.

A report on State Board of Health activities
from the agency’s Gulf Coast Disaster Head-

quarters in the Harrison County Health De-
partment in Gulfport was given by Dr. Frank J.
Morgan, Jr., assistant state health officer.

A report on liaison between the State Board
of Health and the coast-area medical commu-
nity was presented by Dr. Edward C. Hamilton,
vice chief of surgery, Gulfport Memorial Hos-
pital.

Presiding at the two-hour meeting was Walter
C. Hughes, Atlanta, program director, Division
of Emergency Health Service, H.E.W. Hosting
the meeting was Charles Wimberly, administra-
tor, Gulfport Memorial Hospital.

Cardiovascular Specialists
Schedule Session

The American College of Cardiology, the na-
tional medical society for specialists and research
scientists in cardiovascular diseases, will hold its
19th Annual Scientific Session Feb. 25-March 1,
1970 in New Orleans, La. All sessions will be
held at The Rivergate Center.

Major scientific symposia will include such
topics as surgery for complications of myocar-
dial infarctions, cardiac valve substitution and
pulmonary circulation. A new feature at the
meeting this year will be a core curriculum in
clinical cardiology and a self-assessment class
room.

A special group of panel discussions, called
Controversies in Cardiology, will feature discus-
sions by authorities on opposing sides of current
issues. Topics will include prevention of athero-
sclerosis, homografts vs. prosthetic heart valves,
alcoholic heart disease and surgery for coronary
disease.

Doctors attending the meeting will also have a
choice of 20 evening Fireside Conferences, 21
Luncheon panels, Clinical Conversations with
Master Teachers, and a Round of Clinics and
Demonstrations being arranged with hospitals and
medical schools in the New Orleans area, ac-
cording to B. L. Martz, M.D., Indianapolis, Ind.,
college president.

George E. Burch, M.D. and Allan M. Goldman,
M.D., both of New Orleans, La., are general
co-chairmen of the session. Dr. Burch is past
president of the college and professor and chair-
man of the department of medicine at Tulane
University Medical School. Dr. Goldman is pro-
fessor of clinical medicine at the medical school.

JANUARY 1970

45

for the problem drinker

r

TABLETS

high potency B-complex and C
for nutritional support

AVAILABLE ONLY ON Rx
contains water-soluble vitamins only
b.i.d. dosage
good patient acceptance
no odor, and virtually no aftertaste

Each Berocca Tablet contains:

Thiamine mononitrate 15 mg

Riboflavin 15 mg

Pyridoxine HCI 5 mg

Niacinamide 100 mg

Calcium pantothenate 20 mg

Cyanocobalamin 5 meg

Folic acid 0.5 mg

Ascorbic acid 500 mg

Usual dosage is one tablet b.i.d.

Indications: Nutritional supplementation in conditions in
which water-soluble vitamins are required prophylactically
or therapeutically.

Warning: Not intended for treatment of pernicious anemia
or other primary or secondary anemias. Neurologic involve-
ment may develop or progress, despite temporary remission
of anemia, in patients with pernicious anemia who receive
more than 0.1 mg of folic acid per day and who are in-
adequately treated with vitamin B]2.

Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

Roche

LABORATORIES

Division of Hoffmann-La Roche Inc.
Nutley, New Jersey 07110

Israeli Develops
Artificial Limb

An Israeli engineer has introduced a unique
lightweight artificial arm having six movements
which may be operated by electric impulses de-
rived from muscle contraction.

Dr. Dino Bousso of the Technion-Israel In-
stitute of Technology (Haifa, Israel), described
the gas-powered limb as a “marked advance” in
rehabilitation medicine at a press conference at
the Institute of Rehabilitation Medicine of the
New York University Medical Center.

“We are at the stage where we have an arm
much lighter and versatile than anything avail-
able, using electric control and pneumatic pow-
er,” Dr. Bousso declared.

“I welcome this opportunity to bring the arm
to the Institute of Rehabilitation Medicine for
further evaluation.

“It is this type of international cooperation
which furthers our field of expertise — and bene-
fits mankind.”

Dr. Bousso, who developed the 13-ounce arm,
said the limb’s “weight, simplicity and evenness
of motion” are among its unique features. He is
at the Institute on a grant and wants to evoke in-
terest in the Technion-Bousso arm in America.

In describing the arm, which is at the labora-
tory development stage, he said electric muscle
impulses control the gas flow which pneumatical-
ly powers its six movements — the only artificial
limb to perform in such a versatile manner.

Here’s the way the Bousso arm works:

Electrodes, placed on muscles which can be
voluntarily tensed, pick up minute electrical im-
pulses generated in the muscles whenever the pa-
tient’s brain wills them to contract.

These electrical impulses, when amplified, op-
erate a pneumatic solenoid valve that regulates
gas flow into the actuators.

The limb is one-third the weight of other ar-
tificial limbs enabling children to use it, accord-
ing to Dr. Bousso. It is also structured so a
child can recharge the gas container alone.

The arm is comprised of light aluminum al-
loys and high-strength plastic material — mainly
nylon.

Features of the Bousso limb include:

— close simulation of normal arm movements
through use of a special rotary actuator.

— extremely low weight of the limb which uses
gas as its energy source, and doubling of control
signals which can be obtained per muscle.

— simplicity and compactness of the electronic

circuit which can be fitted into the arm itself, and
ease in operating the limb.

Dr. Bousso’s research was supported by a
$40,000 grant from two private British charity
funds — the Lady Hoare Thalidomide Appeal and
the Goudie Trust — designed to help the nearly
5,000 European children afflicted by the drug
while their mothers were pregnant.

Dr. Bousso began his research by concentrat-
ing on developing a rotary actuator which trans-
forms energy directly into rotary motion.

He was able to produce a new type rotary
pouch actuator with high efficiency, low volume
and weight, suited to perform more movements
and carry higher loads than the piston actuators
used up to now.

The result was an artificial limb with six differ-
ent movements. Gripping elements of the limbs
are equipped with optical gauges which indicate
the amount of force exerted.

The limbs are harnessed to the body by a cor-
set molded to the contours of the user. Limb
components can be extended as the child grows.
Working pressure of the gas also can be acceler-
ated to increase its power.

Dr. Dino Bousso of the Technion-Israel Institute
of Technology (Haifa, Israel), displays unique gas-
powered 13 oz. arm — said to be lightest ever con-
ceived. The Technion-Bousso arm, comprised of
aluminum and plastic — mainly nylon, has six move-
ments, also a first, which Dr. Bousso described as a
“marked advance” in rehabilitation medicine.

JANUARY 1970

47

Doctor, after all we’ve
been through together. . .

abscess

acne

amebiasis

anthrax

bacillary dysentery
bartonellosis
bronchitis
bronchopulmonary
infection

brucellosis
chancroid
diphtheria
endocarditis
genitourinary
infections
gonorrhea
granuloma inguinale
listeriosis
lymphogranuloma

mixed bacterial
infection
osteomyelitis
otitis
pertussis
pharyngitis
pneumonia
psittacosis
pyelonephritis

Rocky Mountain
spotted fever
scarlet fever
septicemias
sinusitis

soft tissue infection
tonsillitis
tularemia
typhus fever
urethritis

. . .don’t you think it’s time
we were on a first-name basis?

caii me^AchroV

55

Every pharmacist knows ACHRO® V stands for ACHROMYCIN® V

Contraindications: Hypersensitivity to
tetracycline.

Warning: In renal impairment, since
liver toxicity is possible, lower doses
are indicated; during prolonged therapy
consider serum level determinations.
Photodynamic reaction to sunlight may
occur in hypersensitive persons.
Photosensitive individuals should
avoid exposure; discontinue treatment
if skin discomfort occurs.

Precautions: Nonsusceptible organisms

may overgrow; treat superinfection
appropriately. Tetracycline may form a
stable calcium complex in bone-forming
tissue and may cause dental staining
during tooth development (last half of
pregnancy, neonatal period, infancy,
early childhood).

Adverse Reactions: Gastrointestinal—
anorexia, nausea, vomiting, diarrhea,
stomatitis, glossitis, enterocolitis,
pruritus ani. Skin— maculopapular and
erythematous rashes; exfoliative

dermatitis; photosensitivity;
onycholysis, nail discoloration. Kidney
-dose-related rise in BUN.
Hypersensitivity reactions— urticaria,
angioneurotic edema, anaphylaxis.
Intracranial— bulging fontanels in young
infants. Teeth— yellow-brown staining;
enamel hypoplasia. Blood— anemia, thror
bocytopenic purpura, neutropenia, eosim
philia. Liver— cholestasis at high dosage.
Upon adverse reaction, stop medication
and treat appropriately.

AchromyciifV

Tetracycline

UAB Uses
MIRU Computer

A great deal of human brainpower went into
the planning of the University of Alabama Med-
ical Center’s Myocardial Infarction Research Unit,
but when the unit begins operation next month,
an electronic brain takes over some of the actual
work — a brain which can calculate the interac-
tion of a vast number of details and come up
with a split-second response.

The computer which backs up the operation
of MIRU was installed at a cost of $309,000 and
is programmed solely for the University Hospital
unit, relieving paramedical personnel of many
time-consuming duties and providing a constant
flow of information from patient to memory bank.

Not only will the MIRU computer monitor
bodily functions and provide, with the touch of a
button, almost any kind of information re-
quired by doctors, nurses, or technicians, but it
will constantly increase its store of information
about myocardial infarction, enabling doctors to
expand their knowledge of how to combat the
disease.

The computer is not new — there are other
IBM 1800’s in existence. But what is being done
with it is new and innovative. The computer is
designed to monitor several patients at one time,
instantly providing vital information to those in
charge, whenever they need it.

Previous monitoring systems have been less
flexible than that used by the UAB computer.
There were limitations on which types of re-
search programs could be incorporated without
interfering with the patient monitoring activities.

The MIRU system is continuously collecting
information about the patients in the unit to per-
mit intensive supervision, with alarms for the
staff when significant changes occur. The collect-
ed information is saved on magnetic tape to pro-
vide the tremendous amounts of data needed for
later research use.

In the past, the different functions of monitor-
ing systems had to be separately and indepen-
dently constructed. The new UAB MIRU system
retains common elements which are always avail-
able to be called into action when needed, pro-
viding the flexibility which has previously been
sacrificed in order to gain high computer perform-
ance.

The computer will be programmed to make
life-and-death decisions only when criteria for the
decisions can be stated in quantitative terms by
the doctor. It will always operate under a phy-

sician’s control, whether he is physically present
or not. The machine cannot replace a doctor’s
care, but it will supplement and assist him in
ways a human brain is neither rapid enough nor
vast enough to do.

According to MIRU senior systems analyst
Steven E. Wixson, “The health sciences are now
entering the age of the computer, an age when
stopping a computer’s operation, even for a mo-
ment, may represent a hazard to the patient.’’

The MIRU installation is designed to continue
functioning even when some of the components
fail electronically. Parts of the system are used
primarily for research by the UA School of Medi-
cine faculty — other equipment is for research as
well as for continuous monitoring and evalua-
tion of bodily functions in patients.

Some units of the computer have duplicate
parts which are interchangeable, allowing the re-
search section to assume those functions of the
monitoring section in case of sudden failure in
operation. Such duplication has been the rule
wherever the research needs have justified ex-
penditure for equipment.

Scientists anticipate a day when computer-col-
lected information will enable the physician to
perform his duties in regulating patient care with
more efficiency and accuracy than is now pos-
sible.

Answers to Cancer Quiz

From Cancer Facts and Figures, The Ameri-
can Cancer Society:

1. (b) 15%. The current figure is approximate-

ly 16% of deaths in the U.S.A. are can-
cer deaths.

2. (b) Slightly over 300,000 annual deaths.

3. (b) Slightly over 1 death every two minutes.

4. (c) 55% men/45% women.

5. (c) Lung cancer, 1st approximately 52,000,

and (d) rectal-colon, 2nd approximately

44.000.

6. (a) Lung cancer, 1st approximately 44,000,

and (b) rectal-colon 2nd, approximately

21.000.

7. (b) Breast cancer, 1st approximately 27,-

000 and (d) rectal-colon cancer, ap-
proximately 23,000.

8. (d) Skin cancer.

9. (c) A little over 3,000.

10. (b) Approximately 21 patients in a local
community of 5.000 will be under can-
cer care. Of these, 7 will die. Of the 14
new cases diagnosed during the year, 5
will be cured.

JANUARY 1970

49

ORGANIZATION / Continued

Gastroenterology Course
Planned for Internists

The American College of Physicians (ACP)
will hold a five-day postgraduate course on
“Function and Dysfunction of Gastrointestinal
Tract” Jan. 2-6, 1970 in Bal Harbour, Fla.

The course, being held in cooperation with
the University of Miami School of Medicine, will
be held at the Americana Hotel. It is one of 25
postgraduate courses the ACP is conducting
throughout the United States and Canada during
the 1969-70 academic year to help specialists in
internal medicine keep abreast of new knowledge
and techniques in the diagnosis and treatment
of diseases.

The Bal Harbour course will concentrate on
recent advances in gastroenterology that relate to
normal and abnormal function, particularly
in regard to gastrointestinal secretions and
absorptions. Panel discussions will be concerned
with diagnostic and therapeutic controversies and
will be held daily. Self-assessment examinations
will be available for those internists who wish to
take them.

Martin H. Kaiser, M.D., Miami, Fla. professor
of medicine and physiology (gastroenterology)
at the University of Miami School of Medicine,
is course director. Co-director is Arvey I. Rogers,
M.D., Miami, assistant professor of medicine at
the medical school and chief of the gastroenterol-
ogy section at the Miami Veterans Administra-
tion Hosptial. The faculty for the course will be
drawn from the medical school, with guest lec-
turers from the Albert Einstein School of Medi-
cine, the Mayo Clinic, the University of Illinois,
Boston University and other institutions.

Tri- State Thoracic
Society Meets

Chest specialists from Mississippi, Alabama,
and Louisiana will convene in Biloxi at the
Buena Vista Hotel on Friday and Saturday, Jan.
10 and 11, for the 14th Annual Tri-State Tho-
racic Society Consecutive Case Conference, ac-
cording to an announcement by Dr. Wilfred Cole,
president, Mississippi Thoracic Society.

This special scientific meeting is co-sponsored
by the thoracic societies and tuberculosis and
respiratory disease associations of Mississippi,
Alabama, and Louisiana.

Members of the Mississippi Thoracic Society
featured on the program during the two day ses-
sion include Drs. H. Richard Johnson, Rush Net-
terville, Charles Parkman, Bob Robertson, Walter
Treadwell, and Myra Tyler, all of Jackson. Dr.
G. Boyd Shaw, Jackson, will serve as moderator
for one of the three scientific sessions.

Guest discussants invited for the two day con-
ference will be: Dr. Vernon N. Houk, Atlanta;
Dr. Robert R. Shaw, Dallas; and Dr. Louis
Raider, Mobile.

Other program participants include: Dr. Thom-
as H. Allen, Birmingham; Dr. Jack Green, Mo-
bile; Dr. Robert L. Dillenkoffer, New Orleans;
and Dr. Dean B. Ellithorpe, New Orleans.

Topics for discussion include segmental resec-
tions, pulmonary angiograms, chest trauma, and
middle lobe syndrome.

Further information and advance reservations
can be made by contacting Mississippi Thoracic
Society, P. O. Box 9865, Northside Station,
Jackson, Miss. 39206.

UMC Announces
New Appointments

Seven new appointments went into effect at
the University of Mississippi School of Medicine
in December. Two pathologists at the Jackson
Veteran’s Administration Hospital have received
faculty appointments as assistant professors of
pathology. Dr. Lloyd L. Barta and Dr. Ezatollah
Foroughi.

Dr. Barta, who received his M.D. degree from
the University of Nebraska School of Medicine,
was an intern at McCook Memorial Hospital and
a resident at New Orleans Charity Hospital. He
is acting chief of laboratory service at the V.A.
Hospital.

Dr. Foroughi, holding an M.D. degree from
Teheran University Medical School in Iran, served
his internship at Mercy-Timken-Mercy Hospital
and residencies at Kansas University Medical
Center, St. Luke’s Hospital and New England
Deaconess Hospital.

Instructors joining the faculty are Miss Vicki
G. Hendershot, instructor in surgery (otolaryn-
gology); Dr. Krishna Potnis, instructor in ob-
stetrics-gynecology; and Edward Eugene Thomp-
son, clinical instructor in surgery (otolaryngol-
ogy).

Miss Constance Juzwiak and Miss Carol June
Smith are both new associates in obstetrics-
gynecology, in connection with the nurse-mid-
wifery program.

5 0

JOURNAL MSMA

Con-

ven-

ience!

.

ANTACID

Your ulcer patients and
others will praise it. Specify
DICARBOSIL 144's — 144 tab-
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ID 319 South Fourth Street, St. Louis, Missouri 63102

Burdick

DIRECTED, DEEP-
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WITH THE MW-1
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The MW-l’s simplicity
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of electrode application
have contributed much
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and directed. Treatment intensities may be
preset.

Write us for descriptive literature and com-
plete price information.

KAY SURGICAL INC.

663 North State St. • Jackson, Miss.

Index to Advertisers

Arch Laboratories

51 William S. Merrell Company

44

Breon Laboratories 10A, 10B, 10C, 10D National Drug Company second cover, 36A, 36B

Burroughs-Wellcome 24A New Orleans Graduate Assembly 11

Campbell Soup Company 20A

Geigy Pharmaceuticals 24B, 24C, 24D

Glenbrook Laboratories 8

Highland Hospital 10

Hillcrest Hospital 29

Hynson, Westcott and Dunning 3

Kay Surgical 51

Lederle Laboratories 4, 31, 48

Eli Lilly front cover, 14

Parke Davis 40C, 40D

Poythress 40B

Robins Company 20D, 33

Roche Laboratories 12, 46, fourth cover

Sandoz 40A

G. D. Searle Company 20B, 20C

Stuart Company 34

Wyeth Laboratories 6, 7

Thomas Yates and Company third cover

California's 1970 senate race is shaping up with all sorts of
health care policy overtones. State GOP is said to be easing out
conservative Sen. George Murphy who has throat tumor and can't cai
paign effectively. Favored to run is HEW Secretary Robert Finch
instead, and Democrats will probably nominate popular president oj
San Francisco State College, Dr . S . I . Hayakawa , who, if elected,
would be third Japanese- American in U.S. Senate.

National Medical Association, predominately black professional
society, says that only 6,000 or 3 per cent of nation's M.D. 's are
Negro and that two medical schools, Howard and Meharry, have gradt
ated 83 per cent of them. More blacks are in private practice ths
whites (73 vs. 65 per cent), and black physicians have higher per-
centage of GP's. Three per cent of Mississippi's M.D. 's are black

Alabama's Medicaid program, beginning Jan. 1, will pay physicians
their usual and customary fees, while Mississippi's are held to
50th to 60th percentiles. Alabama program consists of insurance
policies for physicians' services administered by Equitable Life.
Blue Cross is fiscal intermediary for hospital services, and a ban
will handle drug program administration.

The much-shaken Food and Drug Administration has its third commis-
sioner in 18 months. Dr. tiharles 6. Edwards, former high AMA staf
executive, is new commissioner, succeeding far. Herbert L. Ley. Jr.
who lasted a year and a half after replacing the controversial
Dr. James Goddard. FDA has been shoved down to low level in HEW
Hierarchy by Secretary Finch who is chief shaker-upper.

Nobel laureate Dr. Linus Pauling commended oranges as a therapeuti
specific to the 2nd International Congress of Social Psychiatry. ]
said that vitamin C gives increased vigor, protection against viru
and helps healing wounds, in addition to being a probable specific
in schizophrenia. He reported low levels of ascorbic acid in
schizophrenics where investigators discovered only one- third as
much as is found in individuals of normal mental health.

Volume XI
Number 2

February 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL CONSULTANT
Betty M. Sadler

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
James L. Royals, M.D.

President

Paul B. Brumby, M.D.

President-elect
Walter H. Simmons, M.D.

Secretary-T reasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

ORIGINAL papers

Prevention of Maternal
Rh Sensitization; Anti-Rh

Immune Globulin 53 William B. Wilson, M.D.

Direct-Current
Cardioversion With
Diazepam as Sedative

Agent 57 William H. Rosenblatt,
M.D., and Dexter C.
Nettles, M.D.

SPECIAL ARTICLES

Guidelines to Increase
Efficiency of the Hospital

Emergency Department 61 John T. Milam, M.D.

Radiologic Seminar XCII:

Subclavian Steal Syndrome 66 T. S. McCay, M.D.

EDITORIALS

Medicredit: Delivery System
in AMA’s Image

Additives: HEW, FDA,
MSG, LD50

Data Show Appendectomy
Is Safe

The Agony and the
Ecstasy of Taxes

Work and Play OTV
Can Be Dangerous

69 Done With Taxes
71 Tenuous Conclusions

71 Figures in Our Favor

72 Watch the Small Print

73 Snowmobile Menace

THIS MONTH

The President Speaking 68 Best Part of the Job

Medical Organization 79 Formal Opening of New

Headquarters Addition

Copyright 1970, Mississippi State Medical Association

for the debilitated
geriatric patient

TABLETS

high potency B-complex and C
for nutritional support

AVAILABLE ONLY ON Rx
contains water-soluble vitamins only
b.i.d. dosage
good patient acceptance
no odor, and virtually no aftertaste

Each Berocca Tablet contains:

Thiamine mononitrate 15 mg

Riboflavin 15 mg

Pyridoxine HCI 5 mg

Niacinamide 100 mg

Calcium pantothenate 20 mg

Cyanocobalamin 5 meg

Folic acid 0.5 mg

Ascorbic acid 500 mg

Usual dosage is one tablet b.i.d.

Indications: Nutritional supplementation in conditions in
which water-soluble vitamins are required prophylactically
or therapeutically.

Warning: Not intended for treatment of pernicious anemia
or other primary or secondary anemias. Neurologic involve-
ment may develop or progress, despite temporary remission
of anemia, in patients with pernicious anemia who receive
more than 0.1 mg of folic acid per day and who are in-
adequately treated with vitamin Bi2-

Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

Roche

LABORATORIES

Division of Hoffmann-La Roche Inc.
Nutley. New Jersey 07110

MISSISSIPPI STATE MEDICAL ASSOCIATION

7

AMA Names Private
Practice Committee

Dr. W. B. Hildebrand of Menasha, Wis., has
been elected chairman of the American Medical
Association’s Committee on Private Practice dur-
ing its organizational meeting at Chicago.

The committee, a component of AMA’s Coun-
cil on Medical Service, was created by the House
of Delegates at its recent clinical convention in
Denver.

A former president of the American Academy
of General Practice, Dr. Hildebrand has been
a member of the Council since 1968. He is also
an AMA Commissioner to the joint Commis-
sion on the Accreditation of Hospitals. From
1960-64 Dr. Hildebrand served as a member of
AMA’s Commission on the Cost of Medical Care.

Vice-chairman of the new Committee is Dr.
Robert E. Tschantz, of Canton, Ohio.

Other members are: Drs. C. Willard Camalier,

Jr., Washington, D. C.; Burns A. Dobbins, Fort
Lauderdale, Fla.; Frank H. Green, Rushville,
Ind.; Warren A. Lapp, Brooklyn, N. Y.; Clinton
S. McGill. Portland, Ore.

Also, Drs. John G. Morrison, San Leandro,
Calif.; Tom E. Nesbitt, Nashville, Tenn.; Andrew
L. Thomas, Chicago; George W. Wood, III,
Brewer, Maine.

The committee was the final outgrowth of a
planning and development report, and the initial
recommendation was for a Council on Private
Practice. The House of Delegates, however, de-
clined to create a new council and accorded the
group committee status.

Historically, the role of the Council on Medical
Service has been closely related to the private
practice of medicine, and the delegates placed
the committee under this parent body.

It is expected that the new committee will re-
port to the House of Delegates through the Coun-
cil on Medical Service at the Chicago annual con-
vention next June.

LAKELAND NURSING CENTER

“MISSISSIPPI'S NEWEST”

A 105 BED EXTENDED CARE FACILITY, MEDICARE APPROVED, EQUIPPED FOR REHABILI-
TATION OF THE SICK WITH PHYSICAL THERAPY, INHALATION THERAPY, SPEECH THER-
APY AND OCCUPATIONAL THERAPY. OPEN STAFF. FULL TIME MEDICAL DIRECTOR AND
EMERGENCY MEDICAL CALL COVERAGE.

For Admission Call:

WILLIAM F. KLIESCH, M.D.

MEDICAL DIRECTOR AND ADMINISTRATOR
3680 LAKELAND LANE
JACKSON, MISSISSIPPI
DIAL 982-5505

8

THE JOURNAL FOR FEBRUARY 1970

in cardiac edema

gets the water out

spares the potassium

Before prescribing, see complete prescribing in-
formation in SK&F literature or PDR.

Contraindications: Pre-existing elevated

serum potassium. Hypersensitivity to either com-
ponent. Continued use in progressive renal or
hepatic dysfunction or developing hyperkalemia.

Warnings: Do not use dietary potassium sup-

plements or potassium salts unless hypokalemia
develops or dietary potassium intake is mark-
edly impaired. Enteric-coated potassium salts
may cause small bowel stenosis with or without
ulceration. Hyperkalemia (>5.4 mEq/L) has been
reported, in 4% of patients under 60 years, in
12% of patients over 60 years, and in less than 8%
of patients overall. Rarely, cases have been as-
sociated with cardiac irregularities. Accordingly,
check serum potassium and BUN during therapy,
particularly in patients with suspected or con-
firmed renal or hepatic insufficiency (e.g., cer-
tain elderly or diabetics). If hyperkalemia de-
velops, substitute a thiazide alone. If spironolac-
tone is used concomitantly with ‘Dyazide’, check
serum potassium frequently — their combined use
can cause potassium retention and sometimes
hyperkalemia. Two deaths have been reported
in patients on such combined therapy (in one,
recommended dosage was exceeded; in the other,
serum electrolytes were not properly monitored).
Observe regularly for possible blood dyscrasias,
liver damage or other idiosyncratic reactions.
Blood dyscrasias have been reported in patients
receiving Dyrenium (triamterene, sk&f). Rarely,
leukopenia, thrombocytopenia, agranulocytosis,
and aplastic anemia have been reported with the
thiazides. Watch for signs of impending coma in
acutely ill cirrhotics. Thiazides are reported to

cross the placental barrier and appear in breast
milk; thus adverse reactions which have occurred
in adults may occur in the fetus or newborn infant.
Rarely, thrombocytopenia or pancreatitis has de-
veloped in newborn infants whose mothers had
received thiazides during pregnancy. When used
during pregnancy or in women who might bear
children, weigh potential benefits against possible
hazards to fetus.

Precautions: Do periodic serum electrolyte de-
terminations. Do periodic blood studies in cir-
rhotics with splenomegaly. Antihypertensive ef-
fects may be enhanced in postsympathectomy pa-
tients. The following may occur: hyperuricemia
and gout, reversible nitrogen retention, decreasing
alkali reserve with possible metabolic acidosis,
hyperglycemia and glycosuria (diabetic insulin
requirements may be altered), digitalis intoxica-
tion (in hypokalemia). Use cautiously in surgical
patients. Adjust dose of antihypertensive agents
given concomitantly.

Adverse Reactions: Muscle cramps, weak-
ness, dizziness, headache, dry mouth; anaphy-
laxis; rash, urticaria, photosensitivity, purpura,
other dermatological conditions; nausea and vom-
iting (may indicate electrolyte imbalance), diar-
rhea, constipation, other gastrointestinal distur-
bances. Rarely, necrotizing vasculitis, altered car-
bohydrate metabolism, hyperbilirubinemia, par-
esthesias, icterus, pancreatitis, and xanthopsia
have occurred with thiazides alone.

Supplied: Bottles of 100 capsules.

SK

&F

Smith Kline & French Laboratories

February 1970

)ar Doctor:

i 11 to permit physicians to organize professional corporations for
' x benefits has been introduced in 1970 session of the Legislature,
onsored by state medical association, measure is House Bill 48 by
p. Fred Lotterhos of Hinds. Parallel measure has been intro-
ced by Rep. George Rogers of Warren to include attorneys.

Bid by Treasury Department to hobble professional cor-
porations in Tax Reform Act of 1969 was beaten by AMA.

So both Congress and courts have recognized validity
of professional corporations. Physicians favoring bill
should talk it up to legislators.

arp increase in Medicare Part 1-B premium to $3.30 from $4 is
fective July 1, nearly doubling original figure of $3 in I96I3.
t mentioned, however, in howls over physicians’ fees is that
ly 26 cents of increase is earmarked for future rises in medi-

I care charges. HEW Secretary Finch blames big increase on
rmer HEW boss Wilbur Cohen's failing to up price two years ago.

Propraetors are working overtime in Jackson and Washington to
ke cultism legal in Mississippi and profitable under Medicare.

II to license chiropractors may be introduced at any time in
gislature. In Congress, 87 representatives from 30 states are
-sponsoring bills to pay for cult services under Medicare, but

Mississippi Congressmen are among them.

.surance companies and Blue plans have year of grace before having
1 make reports to Internal Revenue Service of payments to M.D. 's.

IS backed down and revised beginning date to Jan. 1, 1971, after
dch carriers and Blues must report payments of $600 or more in
iy year to physicians. Rule has long been in effect for CHAMPUS,
idicare, and Medicaid.

> smoking is the word in every hospital and medical facility of
S. Air Force, both for patients and medical personnel. Air
Lrgeon General, with full backing of Pentagon, prohibits patients'
loking during hospitalization and bans sale of all tobacco pro-
mts in vending machines and hospital base exchanges.

Rowland B. Kennedy
Executive Secretary

10

THE JOURNAL FOR FEBRUARY 1970

Today’s Health Explores
Sensitivity Training

“Sensitivity Training: Fad, Fraud or New Fron-
tier” is the title of a major article in the Jan.,
1970 issue of Today’s Health magazine, the AMA
publication edited primarily for non-professional
readers.

However, sensitivity training is so new and
experimental even physicians are often unfamiliar
with its concepts, techniques and goals; yet an
increasing number of patients are asking for pro-
fessional evaluation.

This article, by Ted J. Rakstis, supplies many
of the answers for physicians to questions they
may be asked — before they are asked.

Sensitivity training comes with many other
names: encounter groups, personal growth labs,
T-groups (“T” for training), awareness experi-
ence confrontation groups, training laboratories,
organizational development and, collectively, the
human potential movement. Whatever the groups
are called, the phenomenon is attracting hundreds
of thousands of Americans of all ages to programs
run by persons who may be either skilled pro-
fessionals or rank amateurs.

The tangle of sensitivity training nomenclature |
suggests that not even the experts can clearly de- II
line it, the author maintains. It incorporates ele- M
ments of psychiatry, sociology, philosophy, educa-
tion, religion and community organization. Its
practitioners number people from these and other ¥
fields; but depending upon his professional back-
ground and personal bias, each person who con-
ducts a sensitivity group has a different focus.

Most sensitivity sessions share several com- f
mon attributes, however. The programs are de-
signed to place people in a group situation.
Through a mixture of physical contact games ;s
and no-holds-barred discussions about each oth- ;
er’s strengths and failures, each group member
hopefully feels less constricted. He will become
more open, readily able to understand himself
and others.

The Today’s Health article analyzes the claims
of both proponents and opponents, as well as the
questions of the skeptics.

The author points out the sensitivity training
boom has come so quickly and assumes so many
forms that most of the experts have been caught
off guard. Neither the American Psychological
Association nor the American Psychiatric Asso-
ciation has an official position.

xJjiff Q/iest

HOSPITAL

(Formerly Hill Crest Sanitarium)

7000 5TH AVENUE SOUTH
Box 2896, Woodlawn Station
Birmingham, Alabama 35212

Phone: 205-836-7201

A patient centered
independent hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 44 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James A. Becton, M.D., F.A.P.A.

CLINICAL DIRECTORS:

James K. Ward, M.D., F.A.P.A.
Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved lor Medicare pa-
tients.

SfcfiM Cues t

HOSPITAL

BIRMINGHAM, ALABAMA

*

\

i

-stees Accredit Jackson - Eighteen schools of nursing in Mis-
j Nursing Schools sissippi have been accredited for 1970 by the

Board of Trustees of Institutions of Higher
-rning. Program includes three hospital diploma schools, four
: calaureate sources, and 11 associate degree programs. UMC,
iversity of Southern Mississippi, Mississippi College, and Wil-
_m Carey College offer B.3. in nursing.

, . Abortion Law Washington - The District of Columbia abortion
[Held Invalid statute was held invalid in federal court to

the extent that it prohibits procedure unless
cess ary for preservation of the mother's life or health." The
:.rt ruled, however, that abortion is unlawful unless performed
,a competent medical practitioner. Basis of edict is denial of
|i process and right of privacy in "removal of unwanted child. "

[licaid Will Pay Memphis - Mayor Henry Loeb says that Missis-
Memphis Care sippi will pay Memphis hospitals from Medicaid

funds for care of its indigents admitted there,
"eement was reached recently after Memphis mayor threatened to
)se hospitals to Mississippi welfare patients unless state paid
"e than $12.50 per day under old program. Loeb claims that per
5m costs in Memphis institutions are $65.

iiatrists Nixed Youngstown, 0. - An appellate court sustained

Ohio Hospitals an Ohio hospital in denying staff privileges

to podiatrists. Suit was filed by applicant
ter refusal of membership and his request for surgical privi-
g;es. Hospital claimed to have acted on basis of statutory
nitations on podiatrists' practice privileges. Although not on
ssissippi hospital staffs, podiatrists perform major surgery
offices.

PA Backs Eight Washington - The Aircraft Owners and Pilots
or Drink Rule Association, a 150,000-member group repre-

senting private aviation, has recommended
option of federal regulation prohibiting anyone from flying an
rplane within eight hours of consuming alcoholic beverages or
king drugs which would impair faculties. While airlines have
ag had a 24-hour nondrinking rule , there is none for private
lots. Some accidents have been attributed to alcohol.

THE JOURNAL FOR FEBRUARY 1970

1 4

Lilly Develops
Topical Steroid

Uniform topical steroidal medication of the
skin is available for the first time in a transparent
plastic occlusive tape introduced by Eli Lilly
and Company. The new drug formulation — Cor-
dran® Tape (flurandrenolone tape, Lilly) — is
practically invisible when in place and can be
masked by applying makeup over it.

Because flurandrenolone is evenly distributed in
the tape’s adhesive, the same dose is applied to
every square centimeter of skin treated.

Cordran Tape is indicated in the treatment of
the following conditions: atopic dermatitis, con-
tact dermatitis, eczema of hands and feet, lichen
planus, lichen simplex chronicus, neurodermatitis,
nummular eczema, psoriasis, seborrheic derma-
titis, and stasis dermatitis. It is not satisfactory
therapy for alopecia areata.

Investigators who evaluated the effectiveness of
Cordran Tape in more than 2,200 clinical tests
reported the response was “good” to “excellent”
in nearly 70 per cent of the cases.

Impervious to moisture, the plastic tape en-

hances diffusion of medication into the skin and
allows the steroid to remain effective for extended
periods. The medication will not rub off, wash
off, or be absorbed by the clothing as is the case
with unprotected creams and ointments.

Cordran Tape also helps to protect the skin
from scratching, rubbing, drying out, and irrita-
tion from handling chemicals.

The tape is made of a thin matte-finish poly-
ethylene film which is slightly elastic, highly
flexible, and acts as a mechanical splint to fis-
sured skin. The medicated adhesive is a syn-
thetic copolymer of acrylate ester and acrylic acid,
which is free of substances of plant origin. The
adhesive surface is covered with a protective pa-
per liner to permit handling and trimming before
application.

As is true of all corticosteroids, the applica-
tion of Cordran Tape is contraindicated in chick-
enpox and vaccinia and in patients with a history
of hypersensitivity to any of the product’s com-
ponents. Cordran Tape is not recommended for
use on lesions exuding serum or in intertriginous
areas, because such lesions favor bacterial growth.

Its use should be reserved for those cases of
dermatoses in which its special features outweigh
a possibly higher incidence of adverse reactions.

—The lowest priced tetracycline— nystatin combination available—

MISSISSIPPI STATE MEDICAL ASSOCIATION

Some degree of reaction, usually minor, was ob-
served in 18 per cent of cases studied in the
clinical trials. Most common side-effects were
burning and irritation, 8.3 per cent; folliculitis,
3.8 per cent; and sensitivity reaction, 1.5 per cent.
Maceration of the skin, miliaria, and drying oc-
curred rarely. In addition, the tape may cause
purpura and stripping of the epidermis. If irrita-
tion develops, the product should be discontinued
and appropriate therapy instituted.

In pregnant patients use of topical steroid
products (including Cordran Tape) should be
avoided since their safety in such use has not
been absolutely established.

Before applying Cordran Tape, the skin should
be gently cleaned and dried. Scales, crusts, dried
exudates, and any previously used ointments or
creams should be removed. After the protective
liner is peeled off, the tape is applied while the
skin is under gentle tension and then is smoothed
down by stroking with moderate pressure to pro-
duce tight adhesion.

In most cases, the tape should be replaced after
12 hours, unless the physician directs otherwise.
When necessary, the tape may be used at night-
time only and removed during the day.

In the clinical trials, 60 per cent of the pa-

1 5

tients received sufficient treatment from one roll
of tape, while the requirements of 85 per cent
were met by two rolls per patient.

Cordran Tape is supplied in rolls which are
7.5 cm. (3 inches) wide and 200 cm. (80 inches)
long. Each square centimeter contains 4 meg. of
flurandrenolone.

Ninth Oncology
Conference Scheduled

The Ninth National Conference on Therapies
for Advanced Cancers will be held Aug. 20-22
(Thurs.-Sat.), 1970, at the University of Wiscon-
sin Postgraduate Center in Madison.

The Division of Clinical Oncology, University
of Wisconsin, is sponsoring the conference. The
chairman is Dr. Fred J. Ansfield, Professor of
Clinical Oncology.

Additional information may be obtained by
writing the program coordinator: R. J. Samp,
M.D., University Hospitals, Madison, Wisconsin
53706.

HIGHLAND HOSPITAL

Asheville, North Carolina

FOUNDED 1904

A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY

Accredited by the Joint Commission on Accreditation and Certified for Medicare

Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho-
therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser-
vice work with families, family therapy and an extensive and well organized activities program, including oc-
cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The
treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may
be realized.

High school facilities for a limited number of appropriate patients are now available on grounds. The School
Program is fully integrated into the hospital treatment program and is accredited through the Asheville School
System.

Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.

Brochures and information on financial arrangements available
Contact: Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions

or

Charles W. Neville, Jr., M.D.

Assistant Professor of Psychiatry and Medical Director
Area Code 704-254-3201

This “case history” runs to some 10,000 pages

This is a typical "case history” of one new drug -or,
rather, a proposed new drug — assembled for submis-
sion to the U.S. Federal Food and Drug Administration.
These volumes are the result of several years’ work by
thousands of professional and skilled personnel in
just one pharmaceutical company's research labora-
tories, and by hundreds of physicians in medical
schools, hospitals, and private practice. They cover
every aspect of experience with this proposed new
agent from chemical laboratory to clinic, from mouse
to man. Each volume could conceivably represent
hundreds of thousands of dollars of financial invest-

ment, countless hours of human effort. This veritable
mountain of data stands behind every new agent
offered to you by pharmaceutical manufacturers — a
reassuring testimonial to the efficacy, safety and
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JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

February 1970, Vol. XI, No. 2

Prevention of Maternal Rh Sensitization:

Anti-Rh Immune Globulin

WILLIAM B. WILSON, M.D.

Jackson, Mississippi

Thirty years ago, Dr. Philip Levine, a pupil of
Dr. Karl Landsteiner, became interested in a case
of an unusual transfusion reaction. This had oc-
curred in a woman of blood group O, who had
received group O blood. This was, of course,
thought to be compatible. Such a reaction was
uncommon, but by no means rare. This woman
had recently been delivered of a stillborn infant,
and because of postpartum hemorrhage, had
been transfused with her husband’s blood. Dr.
Levine demonstrated an abnormal antibody in
the serum of this woman. He surmised that she
might have become sensitized to an unknown
blood factor in the red cells of her child, which
had been inherited by the baby from the father,
but which was foreign to the mother. He thought
that the antibody which he demonstrated in the
mother’s serum was probably an antibody to
this factor.

In the next two years, he recognized that these
hitherto unexplainable, “intragroup” hemolytic
transfusion reactions often occurred in women
who had given birth to infants with the syndrome
known as erythroblastosis fetalis. He postulated

From the Department of Pathology, Mississippi Baptist
Hospital.

Read before the Section on Obstetrics and Gynecology,
101st Annual Session, Mississippi State Medical As-
sociation, Biloxi, May 12-15, 1969.

that these infants’ red cells contained an antigen
which entered the mother’s circulation and stimu-
lated the formation of maternal antibody, which,
in turn, crossed the placenta into the fetal circu-
lation and destroyed the fetal red cells, produc-
ing the syndrome. The responsible antigen was
found to be identical with the blood group, new-
ly discovered by Landsteiner and Wiener, which
they had named the Rhesus or Rh blood group.

In the early 1960s several investigators
working independently of each other began
research on the hypothesis that passive im-
munization of Rh-negative women immedi-
ately after delivery of Rh-positive infants
could prevent maternal Rh sensitization. The
history of study on this subject is traced, and
current use of the anti-Rh immune globulin
is discussed in detail.

For 50 years, it has been recognized that the
administration of antibody concomitantly with
antigen would prevent the antigen from stimu-
lating antibody production in the recipient. This
dates back to the work of Smith,1 who showed,
in 1909, that simultaneous administration of
diphtheria toxin and antitoxin prevented the de-

53

FEBRUARY 1970

ANTI-Rh GLOBULIN / Wilson

velopment of active host immunity to diphtheria.
Since that time, this observation has been amply
confirmed with many different antigens, and is
a cardinal immunologic principle. In 1960, Finn-
proposed that this principle be utilized in pre-
vention of maternal Rh sensitization, by admin-
istration of anti-Rh antibody to Rh-negative
mothers following delivery of Rh-positive in-
fants. It was strongly suspected that an Rh-neg-
ative mother usually became sensitized to her
Rh-positive infant at the time of delivery, by
means of a leakage of fetal blood into the ma-
ternal circulation at the time of placental separa-
tion. Therefore, if administration of anti-Rh anti-
body were to succeed in preventing maternal
sensitization, it would have the best opportunity
of doing so, if given at the time of delivery.

Hamilton,3 in 1962, was the first to try this
idea. The results were indeed impressive. He in-
jected intravenously a high-titer antiserum into
more than 500 Rh-negative women postpartum,
and, of 74 who had subsequent Rh-positive preg-
nancies, none showed Rh sensitization.

INITIAL EFFORTS

Meanwhile, Finn and Clarke,4 in Liverpool,
had begun work on development of a suitable
antibody preparation, which they tested first in
male volunteers, and then clinically, by injecting
it into Rh-negative women immediately after de-
livery of Rh-positive infants. At about the same
time. Pollack, Gorman, and Freda,5 working in-
dependently at Columbia University, initiated an
almost identical project based on the same hy-
pothesis; namely, that passive immunization of
Rh-negative women immediately after delivery
of Rh-positive infants could prevent maternal
Rh sensitization. In 1966 and 1967, extensive,
well-controlled, field trials were carried out in
several medical centers in West Germany, Swe-
den, Great Britain, Canada, and America, and
it was shown that practically every woman given
the anti-Rh antibody within 72 hours after de-
livery of an Rh-positive infant was protected
against development of Rh sensitization.4

In the combined data of these worldwide
trials,4 of 1,886 women injected with anti-Rh an-
tibody following their first delivery, only four
subsequently showed anti-Rh antibodies, repre-
senting a failure rate of only 0.2 per cent. Of
2,006 women left uninjected, 149, or 7 per cent,
developed demonstrable antibodies within a
few months postpartum. However, these re-

sults were not considered the final answer, be-
cause of the possibility that some of the sup-
posedly protected women had actually received
a primary sensitization by their first pregnancy,
which was nevertheless undetectable by in vitro
antibody titration, and which might become ap-
parent only after the stimulus of a second Rh-
positive pregnancy. Fortunately, these fears were
not substantiated, because, of 245 women who
had been given antibody injections following each
of two Rh-positive pregnancies, only one, or 0.4
per cent, became demonstrably immunized after
the second pregnancy, while of 325 women who
were not injected, 41, or 13 per cent, were dem-
onstrably immunized following their second preg-
nancy.

IMMUNOLOGIC MECHANISM

By what immunologic mechanism does the
administration of anti-Rh antibody following de-
livery prevent maternal Rh sensitization? The
exact mechanism is not known. Mollison0 has
suggested that passively administered antibody
combines with the antigen and prevents it from
combining with receptors of the same specificity
on antibody-forming host cells. It has also been
shown that if Rh-positive cells are coated with
anti-Rh antibody before injection into Rh-nega-
tive male volunteers, the formation of immune
Rh antibody is prevented.4 Siskind7 has found
that passive antibody specifically suppresses an
immune response, by binding to the antigenic
determinants on the antigen molecule and com-
petes with antibody-forming host cells for avail-
able antigen. Pollack et al8 found that passively
administered antibody competed with the immu-
nologically competent cells for antigen (or RNA-
antigen complex); or possibly prevented prelim-
inary “processing” of antigen by host macro-
phages. Clarke4 suggested that the passively ad-
ministered antibody acted as a negative feed-
back against production of additional antibody
by the host, and therefore, if exogenous antibody
is administered immediately after antigen, the
process of antibody formation by the host never
begins.

Why is Rh antibody given only post partum,
and not at some time during pregnancy when
maternal sensitization might be expected to oc-
cur? The statistical data shows that almost all ma-
ternal Rh sensitization occurs as a result of trans-
placental hemorrhage of fetal blood into the ma-
ternal circulation at the time of placental separa-
tion, although fetal erythrocytes are demonstra-
ble in the maternal blood stream in gradually in-

54

JOURNAL MSMA

creasing numbers from six weeks’ gestation until
delivery.9 In spite of the presence of fetal eryth-
rocytes in the maternal blood stream during most
of the pregnancy, only 0.1 per cent of Rh-nega-
tive primiparas developed Rh sensitization be-
fore term, according to Pollack, Gorman, and
Freda.3 (However, Woodrow and Donohoe10
found that 7 of 760, or 0.9 per cent, of their pa-
tients developed Rh antibodies during their first
pregnancy.) Apparently, the pregnant mother
has increased tolerance, poorly understood at
present, for the allogeneic tissue of her infant
during pregnancy, but this is rapidly lost post-
partum.

Regardless of whether or not Rh antibodies
are demonstrable in vitro in the months follow-
ing the first pregnancy, this pregnancy usually
serves as the primary immunization of the moth-
er against Rh antigen, and subsequent pregnan-
cies result in an accelerated, secondary-type anti-
body response.11 Since it is much easier to sup-
press the development of a primary sensitization
than a secondary sensitization by the passive ad-
ministration of antibody, it is obviously of great
importance that antibody be given following the
first Rh-incompatible pregnancy. If an Rh-nega-
tive woman does not become sensitized by her
first pregnancy, this does not mean she is less
likely to become sensitized by her second, but
rather her risk is the same as that of a randomly
selected primipara.3

PROTECTIVE EFFECT

The protective effect of ABO-incompatibility
between mother and fetus against maternal Rh
sensitization is, of course, a well-documented,
but incompletely understood, phenomenon, first
noted many years ago by Levine. Although ABO-
incompatible fetal cells could be ‘‘destroyed" by
the naturally occurring maternal anti-A or anti-B
substances, this would not necessarily render
them non-antigenic.4 Clarke4 suggested that the
Rh antigen of the fetal cells is acting only as a
primary antigenic stimulus, while ABO antigen
of the fetal cells may be acting as a secondary
stimulus to the mother, and therefore the ABO
antigens may produce an accelerated immune re-
sponse, while the Rh antigens are unable to stim-
ulate antibodies because of competitive inhibi-
tion. Competition between simultaneously admin-
istered antigens is, of course, a well-recognized
immunologic phenomenon.

ABO-incompatibility between mother and fe-
tus reduces the likelihood of maternal Rh sensiti-
zation by 90 per cent, but, by no means, is a

guarantee against sensitization.3 In the initial
field trials testing the effectiveness of Rh anti-
body in preventing maternal Rh sensitization,
only Rh-negative mothers who were compatible
with their Rh-positive infants in the ABO system
were utilized. This was done because these wom-
en represented the high risk group, and data on
the efficacy of the treatment could be more easily
obtained in this group of women, who had no
complicating partial protection by ABO incom-
patibility. This design of these studies was not
meant to imply that the investigators considered
the ABO-incompatible mothers to have no risk of
Rh sensitization.3

KLEIHAUER TEST

There has been considerable interest in at-
tempts to utilize the Kleihauer test as a criterion
of whether or not to give Rh antibody to a moth-
er. This test demonstrates fetal red cells on the
maternal blood smear by staining the smear for
fetal hemoglobin, and permits accurate quantita-
tion of the size of a transplacental hemorrhage.3
While the likelihood of sensitization to Rh factor
bears some correlation to the number of fetal
cells on the maternal blood smear postpartum
(and therefore to the size of the transplacental,
feto-maternal hemorrhage), the absence of dem-
onstrable fetal cells in the maternal blood by no
means offers assurance that a small, but poten-
tially sensitizing, hemorrhage has not occurred.
Different series have shown that from 15 to 50
per cent of women who subsequently become
Rh sensitized had negative Kleihauer tests for
fetal red cells postpartum.4- 3- 10 It has been
suggested that women with a positive Kleihauer
test postpartum may require larger doses of anti-
body than those with negative tests,4- 10 although
this is probably best avoided because of the pos-
sibility of a paradoxical enhancement of the im-
mune response.3

RARE EXCEPTIONS

What is the explanation for those rare cases in
which anti-Rh antibody was administered post-
partum in standard doses, but in which maternal
sensitization nonetheless occurred? One possible
explanation is that a previous, sensitizing preg-
nancy had occurred, ending in abortion, unrecog-
nized by the mother and unreported to the in-
vestigators.4 Other possible explanations include
unrecognized, very large transplacental hemor-
rhages, or previous, unknown, Rh-positive blood
transfusion.4 Some of the women had received

5 5

FEBRUARY 1970

ANTI-Rh GLOBULIN / Wilson

measles immune globulin during pregnancy,
which probably was contaminated with Rh anti-
gen.-’ Probably most failures are the result of
large transplacental hemorrhages, for which the
dose of antibody was inadequate. The standard
dose in America is now 0.3 mg. of anti-Rh im-
munoglobulin G,5 which is sufficient for a hemor-
rhage up to 10 ml. — a very large hemorrhage.

Certain obstetrical factors have been shown to
increase the likelihood of Rh sensitization, and
these are toxemia of pregnancy, cesarean sec-
tion, breech delivery, and an interval of less than
one year between the first and second preg-
nancies.12 Manual separation of the placenta,
versions, assisted vaginal delivery, and amnio-
centesis are also thought to predispose to trans-
placental hemorrhage and result in an increased
likelihood of maternal Rh sensitization.

EXTENT OF USE

A pertinent question regarding the use of Rh
antibody is whether to give it to all Rh-negative
women who have an abortion. The exact likeli-
hood of maternal Rh sensitization following an
abortion or miscarriage has not been accurately
determined statistically to date.5 In a fairly small
series, Matthews, quoted by Clarke,4 found that 7
of 155 (4.8 per cent) of women having spon-
taneous abortion followed by curettage, had
demonstrable fetal cells in their peripheral blood
postpartum. Therapeutic abortion, which, of
course, usually occurs later in pregnancy than
spontaneous abortion, either by the vaginal or
abdominal routes, resulted in much higher in-
cidence of demonstrable fetal cells in the ma-
ternal blood; namely, about 25 per cent, with 5
per cent of these showing large numbers of fetal
red cells. There is consensus among all the work-
ers in this field4- 5- 10- 11 that all Rh-negative
women, especially primiparas, who have an abor-
tion, miscarriage, or ectopic pregnancy, should
be given anti-Rh antibody. The only exceptions
would be if the fetus is large enough for an Rh
typing, and is shown to be Rh negative; or if the
mother is already demonstrably sensitized, with
Rh antibodies in her serum; or if it is known
with certainty that the biologic father is Rh-nega-
tive.

It is evident that the proper use of anti-Rh
immune globulin depends upon discovering, be-
fore 72 hours postpartum, which women are Rh-
negative. In others words, adequate case-find-
ing, within the specified time limit, is essential to
the effective use of this product. Therefore, it is
advocated that all women admitted for obstetrical
purposes to the hospital should have an Rh type
and ABO grouping routinely done on admission.18
This should be done by the saline-tube method,
since the simpler slide method may give a false
positive in pregnant women. Although many pa-
tients have had an Rh type done by their physi-
cian before delivery, a routine test on admis-
sion is considered desirable, to make sure no
Rh-negative patients are missed, and also to de-
tect possible errors in previous Rh typing. Such
an error could mislead the physician into recom-
mending anti-Rh immune globulin when it is not
needed, as in a D" mother mistyped as Rh-nega-
tive; or into failing to give anti-Rh immune globu-
lin when it is needed, possibly making the physi-
cian and hospital liable, if Rh sensitization should
develop in a subsequent pregnancy. ***

North State and Carlisle Streets (39201)

REFERENCES

1. Smith, T.: Active Immunity Produced by So-called
Balanced or Neutral Mixtures of Diphtheria Toxin
and Antitoxin, J. Exper. Med. 11:241-56, 1909.

2. Finn, R.: Erythroblastosis, Lancet 1:526, 1960.

3. Hamilton, E. G.: Prevention of Rh Isoimmuniza-
tion by Injection of Anti-D Antibody, Obstet. Gynec.
30:812, 1967.

4. Clarke, C. A.: Prevention of Rhesus Iso-immuniza-
tion, Lancet 2:1-7, 1968.

5. Pollack, W.; Gorman, J. G.; and Freda, V. J.: Pre-
vention of Rh Hemolytic Disease, Prog. Hemat. 6:
121-47, 1969.

6. Mollison, P. L.: Blood Transfusion in Clinical Med-
icine. ed. 4, Philadelphia, F. A. Davis Company,

1967.

7. Siskind. G. W.: The Role of Circulating Antibody
in the Control of Antibody Synthesis, Transfusion
8:127-33, 1968.

8. Pollack, W., et al: Antibody-Mediated Immune Sup-
pression to the Rh Factor, Transfusion 8:134-45,

1968.

9. Clayton, E. M.; Feldhaus, W.; and Phythyon, J. M.:
Transplacental Passage of Erythrocytes During
Pregnancy, Obst. & Gynec. 28:194, 1966.

10. Woodrow, J. C.; and Donohoe, W. T. A.: Rh-Im-
munization by Pregnancy: Results of a Survey and
Their Relevance to Prophylactic Therapy, Brit.
M. J. 4:139-44, 1968.

11. Editorial, Suppressing Rh-Immunization, Brit. M. J.
4:135-6, 1968.

12. Knox, E. G.: Obstetric Determinants of Rh Sen-
sitization, Lancet 1:433, 1968.

13. Wilson, W. B.: Letter to the Editor, J.M.S.M.A. 9:
486-8, 1968.

56

JOURNAL MSMA

Direct- Current Cardioversion
With Diazepam as Sedative Agent

WILLIAM H. ROSENBLATT, M.D., and
DEXTER C. NETTLES, M.D.

Jackson, Mississippi

The reversion of tachyarrhythmias to regular
sinus rhythm by a synchronous direct-current con-
verter originally described by Lown1 in 1962
and subsequently by others2-4 has now become a
widely accepted procedure. Until recently most
clinicians performing cardioversion used a nar-
cotic analgesic such as meperidine in conjunction
with a barbiturate,2 or general anesthesia,3 or
short-acting barbiturates that induced light sleep.4
However, these agents require the presence of an
anesthesiologist. In addition, barbiturates and
narcotics frequently mask subtle signs and symp-
toms of cardiac irregularities that may occur after
conversion2 and have other drawbacks and con-
traindications as well.

Over the past two years we have effected car-
dioversion in 20 patients by using a single in-
travenous injection of diazepam (without ancil-
lary anesthetic measures) for producing transient
sedation and amnesia.

All patients were hospitalized. One subject had
thyrotoxicosis, 12 had arteriosclerotic heart dis-
ease, and 7 had rheumatic heart disease (with
mitral insufficiency in 3 and mitral stenosis in 4
patients). The patients were in chronic atrial
fibrillation except for 2 who had, respectively,
ventricular tachycardia or atrial flutter.

In subjects undergoing elective cardioversion,
digitalis was discontinued 7 to 10 days previous-
ly, and premedication with quinidine sulfate, 200
mg. every 6 hours, was started 24 hours prior to
the procedure. This preparation was of necessity
omitted in 1 patient (Case 19) who required
emergency cardioversion.

From the Department of Medicine, Mississippi Baptist
Hospital.

The procedure was performed in the emergen-
cy room the morning following admission to the
hospital. A preconversion electrocardiogram was
recorded on a standard ECG machine connected
by cable to the direct-current electrical converter.
A follow-up record of the ECG was obtained
during the actual conversion and immediately
following application of the countershock.

A 20-case series is presented in which a
single intravenous injection of diazepam
used as sedative agent during direct-current
countershock in 20 patients was well toler-
ated. Methods and materials are discussed,
and results are tabulated.

Vital signs including the rate and amplitude of
respiration, pulse rate and blood pressure were
recorded prior to and immediately following re-
version and every 15 minutes until full conscious-
ness returned.

Undiluted diazepam (5 mg ml) was adminis-
tered slowly intravenously at a rate of 5 mg. per
minute until slurring of speech was observed.
The direct-current countershock was delivered
immediately thereafter by the technic described
by Lown1 using an American Optical Cardio-
verter and anterior chest paddle electrodes.

The etiology of heart disease, age and sex of
the patient, dosage of diazepam, energy of last
electrical shock, and existence of complications
are listed for each patient in Table 1.

All but 3 subjects reverted to regular sinus
rhythm following application of direct-current
countershock. The initial shock administered was

FEBRUARY 1970

5 7

CARDIOVERSION / Rosenblatt et al

150 watt-sec delivered in 0.0025 sec. If repeated
shocks were required, each was increased by 50
watt-sec to a maximum of 400 watt-sec. The
number of discharges required for reversion
varied from 1 in 10 patients to 2 to 5 in 8 sub-
jects, and 1 person received 1 1 immediately suc-
cessive shocks before reversion to normal sinus
rhythm occurred. Three patients with arterio-
sclerotic heart disease and atrial fibrillation failed
to revert after 3 and 5 shocks, respectively (Table
1).

The usual range of dosage for diazepam was
10 to 20 mg.; 1 person received less than 10 mg.

TABLE 1

ATRIAL FIBRILLATION (N=18), ATRIAL FLUTTER
(N=l) OR VENTRICULAR TACHYCARDIA (N=l)
TREATED BY DIRECT-CURRENT COUNTER-
SHOCK WITH INTRAVENOUS DIAZEPAM
AS SEDATIVE AGENT

• o'
a, <

Age

Sex

Etiology
of Heart
Disease

Sr

q £

Number of
Shocks

Last Shock
( Watt-sec )

Reversion
to Normal
Sinus Rhythm

1

60M

ASHD

20

2

200

T

2

58M

ASHD

10

1

100

+

3

69F

RHD

20

1

100

+

4

69F

RHD

25

11

100

+

5

39F

RHD

20

2

200

+

6

39F

RHD

15

2

200

+

7

68F

RHD

10

1

200

+

8

68F

ASHD

20

5

400

-

9

60M

ASHD

20

2

200

+

10

60M

ASHD

20

1

100

+

11

58F

RHD

10

1

100

+

12

61F

ASHD

20

3

300

-

13

72F

ASHD

7

1

100

+

14

59F

ASHD

12

1

100

+

15

64M

ASHD

30

3

300

-f

16

65 F

RHD

10

1

150

+

17

52M

ASHD

12

1

150

18

56M

ASHD

16

1

150

+

19*

59M

Thyrotox

20

2

200

+

20*

6 IF

ASHD

10

12

400

-

* For description of complications following counter-
shock ( see text). ASHD = Arteriosclerotic heart disease.
RHD = Rheumatic heart disease.

and 2 more than 20 mg. (25 and 30 mg. respec-
tively). All patients, including those who were
noticeably apprehensive on arrival at the emer-
gency room, were calm and tranquil following
injection of diazepam. Within one to three min-
utes they became drowsy or fell into light sleep

lasting 30 to 45 minutes during which they could
be easily aroused when spoken to. When ques-
tioned immediately on awakening or 24 hours
later, the patients usually had no recall of the
cardioversion. Two subjects (receiving multiple
shocks) complained of severe chest pain at the
time of the delivery of the shock, but only 1 of
these could later accurately recall the procedure.

NO ABNORMALITIES

Neither the rate (8 to 12 per minute) or the
depth of respiration was altered by diazepam,
and no hypotension or abnormal cardiac rhythm
attributable to diazepam was observed.

Serious immediate complications of cardiover-
sion in 2 patients were due to excessive digitalis.
A 59-year-old man (Case 19) with thyrotoxicosis
was found dead in his hospital bed the morning
following cardioversion. He had been receiving
large doses of digoxin which could not be safely
discontinued. He had reverted to normal sinus
rhythm following the second countershock, but a
few minutes later bigeminal rhythm developed
and persisted for several hours. A 61-year-old fe-
male (Case 20) with arteriosclerotic heart disease
and atrial fibrillation had also been receiving very
large doses of digitalis. She reverted to sinus
rhythm following 12 successive countershocks,
but about 30 minutes later bidirectional ventricu-
lar tachycardia developed and lasted 24 hours,
and she relapsed into atrial fibrillation.

None of the other major complications de-
scribed infrequently following cardioversion, such
as prolonged cardiac asystole or systemic or pul-
monary embolism, was observed.

USE OF SEDATIVES

Although some clinicians elect to perform car-
dioversion without anesthesia,5 most advocate
the use of sedation as the discomfort in the con-
scious patient is generally unpredictable and may
be great, varying directly with the magnitude of
the electrical discharge. In addition, multiple or
high energy shocks make the patient apprehen-
sive and are particularly uncomfortable. The sen-
sation is that of a sudden jolt or transient pres-
sure across the chest, which has been described
by patients as “feeling like someone struck me
in the chest with a baseball bat,” or “a sensation
like a horse kicked me in the chest.”

Diazepam (Valium®), a benzodiazepine de-
rivative related to chlordiazepoxiae (Figure 1),
has been used extensively to reduce anxiety and
tension in a wide variety of clinical situations.6
The drug also has central muscle relaxant and

58

JOURNAL MSMA

STRUCTURAL FORMULA OF DIAZEPAM

®

VALIUM (DIAZEPAM)

7- CHLORO -I-METHYL-5-PHENYL-
3 H - 1 , 4 - BENZODIAZEPIN-2 (IH)-ONE

Figure 1

anticonvulsant properties and is employed for the
relief of muscle spasms in musculoskeletal dis-
orders,7 cerebral palsy,8 and tetanus,9 and for
control of convulsive seizures.10 When used as
premedication in surgical and endoscopic proce-
dures, diazepam has been reported to produce a
calm, relaxed state in which the patient tends to
be unconcerned with, and later has little or no re-
call of, the operative experience.10- 11 In thera-
peutic dosage diazepam appears to have lesser
propensity to depress circulation or respiration
than barbiturates or narcotics.9-12 Circulation
and respiratory responses were not altered sig-
nificantly by diazepam in healthy subjects.13-15

In the present study, diazepam produced tran-
sient but adequate sedation and amnesia, thus
confirming previous reports of its particular use-
fulness as adjunctive medication in patients un-
dergoing cardioversion.16-20 No clinically signifi-
cant hemodynamic or respiratory changes were
observed in these studies,16-19 and cardiac out-
put was not reduced.20

Unlike barbiturates or narcotics, diazepam re-
lieved anxiety without producing oversedation.
The period of light sleep, from which patients
could be easily aroused, in our cases ranged

from 30 to 45 minutes, which is somewhat longer
than that reported by Winters et al18 and by
Lown20 but shorter than that observed in some
instances by Kahler et al.17

Except for 1 of 2 patients who experienced
severe pain following a relatively high discharge
of energy, the patients had no recall of the car-
dioversion on awakening nor 24 hours later.

We noted no significant effects related to
diazepam on cardiorespiratory parameters or au-
tonomic functions.

ATRIAL DISORDERS

From our data and the data reported by oth-
ers, it appears that in about 85 per cent of all
patients atrial fibrillation and atrial flutter can be
safely and effectively reverted to regular sinus
rhythm by application of direct-current counter-
shock. Digitalis-induced rhythm disorders are im-
pervious to cardioversion. Conduction distur-
bances or atrial, nodal, or ventricular ectopic beats
due to digitalis toxicity have been described not
uncommonly following the reversion of atrial
fibrillation and the restoration of normal sinus
rhythm.1- 2 Apparently the amount of digitalis
necessary to control the ventricular rate during

FEBRUARY 1970

59

CARDIOVERSION / Rosenblatt et al

atrial fibrillation may cause toxic effects during
normal sinus rhythm.2 In most instances these
disturbances disappear if digitalis is withheld
prior to reversion. However, as in the two epi-
sodes of complications due to excessive digitalis
observed in our series, this may not be practica-
ble in some instances.

SUMMARY

A single intravenous injection of diazepam
used as sedative agent during direct-current
countershock in 20 patients was well tolerated.
The drug simplified the procedure from the
standpoint of obviating the use of general anes-
thesia, or barbiturates and narcotics. Generally 10
to 20 mg. diazepam sufficed for rapid, transient
sedation and amnesia. The onset of drowsiness or
light sleep occurred in one to three minutes after
the injection; the patients became fully respon-
sive in 30 to 45 minutes and usually had no re-
call of the countershock. In this dosage diazepam
had little or no effect on respiration or circula-
tion. Reversion by the procedure described is far
safer than drug or medical cardioversion and can
be readily mastered by the general practitioner.

★★★

1151 North State St. (39201)

REFERENCES

1. Lown, B.; Amarasingham, R.; and Neuman, J.:
New Method for Terminating Cardiac Arrhythmias,
J.A.M.A. 182:548 (Nov. 3) 1962.

2. Paulk, E. A.. Jr.; and Hurst, J. W. : Clinical Prob-
lems of Cardioversion. Am. Heart J. 70:248 (Aug.)
1965.

3. Morris, J. J., Jr.; Kong, Y.; North, W. C.; and Mc-
Intosh, H. D.: Experience with “Cardioversion” of
Atrial Fibrillation and Flutter, Am. J. Cardiol. 14:94
(July) 1964.

4. Shephard, D. A. E.; and Vandam, L. D.: Anesthesia
for Cardioversion, Am. J. Cardiol. 15:55 (Jan.)
1965.

5. Stock, R. J.: Cardioversion without Anesthesia,

New England J. Med. 269:534 (Sept. 5) 1963.

6. Svenson, S. E.; and Gordon, L. E. : Diazepam. A
Progress Report, Current Therapy Res. 7:367 (June)

1965.

7. Peirson, E. W.; Fowlks, E. W.; and King, P. S.:
Long-Term Follow-up on the Use of Diazepam in
Treatment of Spasticity, Am. J. Phys. Med. 47:143,
1968.

8. Engle, H. A.: The Effect of Diazepam (Valium) in

Children with Cerebral Palsy: A Double-Blind

Study, Develop. Med. Child. Neurol. 8:661 (Dec.)

1966.

9. Lockwood, W. R.; and Allison, F., Jr.: Injectable
Diazepam: A New Drug for the Treatment of
Tetanus, J.M.S.M.A. 8:66 (Feb.) 1967.

10. Bailey, D. W.; and Fenichel, G. M.: The Treatment
of Prolonged Seizure Activity with Intravenous
Diazepam, J. Pediat. 73:923 (Dec.) 1968.

11. Tornetta, F. J.: Diazepam as Preanesthetic Medica-
tion: A Double-Blind Study, Anesth. Analg. 44:449
(July-Aug.) 1965.

12. Ticktin, H. E.; and Trujillo, N. P.: Further Experi-
ence with Diazepam for Pre-endoscopic Medication,
Gastroint. Endosc. 15:91 (Nov.) 1968.

13. Steen, S. N.; Weitzner, S. W.; Amaha, K.; and
Martinez, L. R.: The Effect of Diazepam on the
Respiratory Response to Carbon Dioxide, Canad.
Anaesth. Soc. J. 13:374 (July) 1966.

14. Sadove, M. S.; Balagot, R. C.; and McGrath, J. M.:
Effects of Chlordiazepoxide and Diazepam on the
Influence of Meperidine on the Respiratory Re-
sponse to Carbon Dioxide, J. New Drugs 5:121,
( March-April) 1965.

15. Katz, J.; Finestone, S. C.; and Pappas, M. T.: Cir-
culatory Response to Tilting after Intravenous Di-
azepam in Volunteers, Anesth. Analg. 46:243
(March-April) 1967.

16. Nutter, D. O.; and Massumi, R. A.: Diazepam in
Cardioversion, New England J. Med. 273:650 (Sept.
16) 1965.

17. Kahler, R. L.; Burrow, G. N.; and Felig, P.: Diaze-
pam-Induced Amnesia for Cardioversion, J.A.M.A.
200:997 (June 12) 1967.

18. Winters, W. L., Jr.; McDonough, M. T.; Hafer, J.;
and Dietz, R.: Diazepam. A Useful Hypnotic Drug
for Direct-Current Cardioversion, J.A.M.A. 204:
926 (June 3) 1968.

19. Muenster, J. J.; Rosenberg, M. S.; Carleton, R. A.;
and Graettinger, J. S.: Comparison Between Diaze-
pam and Sodium Thiopental during DC Counter-
shock, J.A.M.A. 199:758 (March 6) 1967.

20. Lown, B.: Cardioversion, J. Oklahoma M.A. 62:285
(July) 1969.

60

JOURNAL MS M A

Guidelines to Increase Efficiency
Of the Hospital Emergency Department

JOHN T. MILAM, M.D.
Cleveland, Mississippi

A rather marked change in medical practice
has taken place gradually since World War II.
The use of the hospital for inpatients as well as
emergency patients has rapidly increased during
this interim. Housecalls have been frowned upon
and gradually have become fewer. Physicians dis-
like coming to their offices except for regular
hours, and they have become more unavailable
at night, holidays, and weekends. Often when
they have been called, they have referred their
patient to the hospital emergency department be-
cause some doctor would be present and could
take care of the situation. Therefore, because the
patients’ problems are no longer limited to pri-
marily charity and injury cases, the accident
room gradually has emerged into the emergency
room and is now considered in the form of an
emergency department. This department is where
not only emergency and charity patients are
treated, but also cases of colds, headaches, fever,
pain and anxiety states are treated in lieu of going
to the doctor’s office.

The emergency department as it exists today
within hospitals has become in many instances
an acute problem. Multiple and complex diffi-
culties regarding this service would include the
legal implications, medical education of the house
staff, public relations, physician staffing and the
assurance of rendering quality medical care.
These problems have become acute due to the
fact that the use of the emergency room has be-
come an area of greatly increased activity by the
public. Once primarily used for the treatment of
minor type emergencies such as lacerations and

Read before the 92nd semi-annual meeting, the Delta

Medical Society, Indianola, October 8, 1969.

simple fractures and also for the use of the char-
itable patient, now the emergency service is
viewed by the community as a place to get gen-
eral medical attention promptly, regardless of
what is needed.

During the past decade the American popula-
tion has expanded at an annual rate of \Vi to 2

Since World War 11 the old “ accident
room ” of the hospital has developed into a
community medical center for all types of
care. The resulting increased use puts pres-
sure on both the personnel and the space of
today's hospitals. The author discusses the
problems presented by the emergency room's
new role and suggests some solutions.

per cent. During this same period visits to the
emergency departments have increased at a rate
of approximately 6 per cent per year. To handle
efficiently this rapidly increasing number of pa-
tients, hospitals must first accept the existence of
this dramatic change that has and will continue to
have profound impact upon health care through-
out the country. The American College of Sur-
geons after several years of study published in
1963 an excellent comprehensive article on
“Standards for Emergency Departments in Hos-
pitals.” One part of the article states in effect that
it should be the policy and function of the general
hospital to make adequate appraisal and to ren-
der necessary initial care to anyone who presents
himself at the emergency area. Every person
within the health care field — physician, hospital
administrator, or health economist — must be-

FEBRUARY 1970

61

HOSPITAL EFFICIENCY / Milam

come vitally concerned with the rapidly increas-
ing number of emergency department visits by
patients. Failure to properly handle this problem
will have a most unfortunate and negative im-
pact on community relations with the hospitals.

There are three primary causes for the in-
creased use of emergency departments. One is that
the hospital has become a center for casual medi-
cal care. Private medicine appears to be develop-
ing into a system of formal appointment and re-
ferral type of medical practice. The more infor-
mal nonappointment casual type of practice
which is ever increasing has been relinquished
to the institutions. Therefore, the hospital emer-
gency department has become the center for su-
permarket medicine in many areas.

INCREASED USAGE

A second cause is the significant change in the
total capacities of medicine. Thirty years ago the
individual physician with his symbolic black bag
had a far greater capacity to bring to the patient
all of what was then medical science than he has
today. He was considered at that time to be an in-
dependent self-sufficient unit. Today the modern
physician is a part of a complex multidisciplined
team of professional, semi-professional and tech-
nical personnel. He may be considered a prism
through which all the resources of modern medi-
cine are focused onto one individual’s needs. The
entire structure is obviously useless without the
physician. Equally, the physician has greatly de-
creased capacity when separated from this great
milieu of skills and facilities available to him.
The center of this complex health care structure
is, of course, the hospital. Here and in this type
of assignment the physician can offer his patient
a much greater and more beneficial range of
health care than he can under any other cir-
cumstance.

A third cause of the increased number of
emergency department visits is the greatly in-
creased mobility of the population as well as the
increase in birth rate and life span. Today with
good methods of immediate transportation, peo-
ple are no longer more or less home-bound.
There usually is a car in the garage or in the
neighbor’s garage. As a result, a person with
even a relatively simple injury is brought to the
hospital emergency department which is the one
place recognized by the community as a health

care area which is always available and ready at
the patient’s beck and call.

Increased volume and use of vehicular traffic
has, of course, resulted in a substantial increase
in the number of accidents, almost all of which
are cared for within the emergency rooms.

POOR IMAGE

Frequently hospitals may present a poor pub-
lic image rather than winning the supportive at-
titude which is so vital to the future of the hos-
pital. This poor image may come about in many
ways and due to many acts. For instance, the pa-
tient visiting the emergency department may have
to sit in a drafty corridor along with 15 to 20
other outpatients for a considerable length of
time. He may have to be cared for in facilities that
have long since past their point of greatest effi-
ciency. This naturally results in harassment to
the professional and technical staff, who under
the best circumstances find it difficult to keep
pace with the ever increasing number of pa-
tients they are required to serve.

The patient may tend to compare his care in
the emergency department with the inpatient ser-
vice which he may have received some previous
time. There, of course, is marked contrast in that
the inpatient service is markedly immaculate,
well organized, and an air of pleasantness and
efficiency prevails, whereas in the emergency de-
partment the patient may feel that he is being
given the “run around.” He also generally views
his condition as of immediate or emergency na-
ture which it may or may not be. Any wait, how-
ever short in duration, seems to him to be in-
tolerable.

UNAVOIDABLE INSTANCES

Of course, this waiting period is inevitable
and unavoidable in many instances. The profes-
sional and technical staff constantly must attempt
to sort out the patients who require the greatest
attention and care in the shortest time. The wait-
ing individual has little or no opportunity to un-
derstand this, and too frequently a harassed staff
working in less than adequate facilities does not
present to the patient the same kind of calm,
competent attitude that he encounters as an in-
patient on a nursing unit.

All of these factors create apprehension, mis-
understanding, and often a negative attitude on
the part of the patient towards the institution
concerned.

62

JOURNAL MSMA

Most hospitals in the United States undertake
to furnish some type of emergency care and ser-
vice and in so doing will thus assume a definite
legal responsibility. The legal scope of the ser-
vice is difficult to define since there are seldom
any written guidelines. Quality of emergency care
is apt to be determined by a number of factors
including primarily the customs and practices of
a community, the availability of other care, and
the financial burden.

Since only a licensed physician can lawfully
make a diagnosis and since a diagnosis must be
obtained in order to determine whether medical
care can safely be delayed by putting the patient
off until the next day or referring him to his per-
sonal physician, the emergency care of a hospital
should be under the direct supervision of a li-
censed physician. A licensed physician in charge
of the emergency service or one available on
call within a reasonably short period of time
should be available for the emergency service at
all times. Where a hospital undertakes emergency
care, the governing body and the medical staff
have a joint responsibility to insure adequate di-
rection and supervision of the emergency depart-
ment.

MEDICAL DECISIONS

The final decision as to whether or not an
emergency exists must be in conformity with
good medical practice. Injuries may result from
negligent decisions regarding emergency and may
lead to possible liability to either hospital or the
physician or both.

If care is undertaken by the physician within
the hospital emergency area, liabilities would be
little to no different from that which exists with
respect to regular inpatients. Liability would arise
only if injury to the patient resulted from negli-
gence in giving care or in providing adequate fa-
cility for him. This, of course, would be mea-
sured by the prevailing standard of care in the
community or in similar communities under sim-
ilar circumstances.

The standard emergency care in the emergen-
cy room is considered legally less rigorous than
that for care of hospitalized patients. This is
true because consideration is given to the cir-
cumstances under which this care is given. Also,
the urgency present in the emergency case and
the inability in many cases for complete prepa-
ration, complete workup and diagnosis can well
explain and more or less justify unfortunate in-
cidents which might not be excusable in the more
orderly treatment of regular hospitalized patients.

Quality of care in the emergency department

may be measured by many methods. We would
agree that good hospital facilities — plant and
equipment — do not assure high quality of care;
however, they must be considered to be of great
importance. Personnel is all important in quality
of care — education, experience, interest, natural
ability — but there are other factors which also
have a profound effect. These include availabil-
ity, administration, examining rooms, equipment,
personnel, standing operating procedures, triage,
over-taxed facilities, records, communications,
complementary inpatient services and the emer-
gency department committee.

VISIBLE DIRECTIONS

There are many hospitals with no “emergency”
or “hospital" sign visible to the public until the
emergency door is reached. In this motor age, all
roads leading to a hospital should have signs
pointing to the facility itself and to the emergency
service area. These signs should not be hidden
from view by natural or man-made objects and
should be visible at night. In other words, the
stranger should not have to take time to ask di-
rections in order to get to the emergency en-
trance.

Sufficient clerical help is necessary to obtain
and to record the pertinent information pertain-
ing to the patient. Nurses should not have to
spend time writing down names, addresses and
collecting money; this, of course, is a function of
the business office.

The examining room should provide adequate
privacy for the patient. Each area needs stretchers
and wheelchairs. The equipment provided for the
emergency area should be consistent with the
equipment which is used in any other part of the
hospital. All supplies should be marked and
readily identifiable. The x-ray department and
the lab should be adjacent to or at least on the
same floor as the emergency area.

PERSONNEL REQUIREMENTS

Dependability and promptness of personnel
are of prime importance. Attention should be
given to securing or having available the correct
and necessary personnel and assistants when
needed. Too often the largest number of person-
nel are on duty on the day shift while the evening
shift is usually the busiest.

Standing operative procedures, both adminis-
trative and professional should be available in
every emergency department. An emergency de-

FEBRUARY 1970

63

HOSPITAL EFFICIENCY / Milam

partment committee should determine policy for
the facility, subject to the approval of the medi-
cal staff.

In many institutions the patient load is such
that treatment priorities must be assigned. Other-
wise without triage over-crowding and hasty
treatment may result.

Over-taxed facilities within the emergency area
must be guarded against such as inpatient pro-
cedures, pre-employment hospital physical exam-
inations, minor surgery, re-visits, dressings. The
quality of the emergency work suffers under
these conditions. In many instances where this
takes place multiple-injury patients brought in by
ambulance have been left on stretchers for a
time because no examining tables were avail-
able.

A definite system of records review is quite
important in the emergency department. This
type of audit should be considered to be as im-
portant as the inpatient care audit in order to
help keep high quality controls.

GOOD COMMUNICATION

Good communication is necessary between
the hospital emergency department and outside
emergency services — police, fire, ambulance and
civil defense. Unfortunately, most generally this
quick communicative service is rare. Two-way
radio could give important advanced notification
to the emergency department staff and should be
considered whenever possible.

Complementary services such as intensive care
units and coronary care areas are becoming com-
mon within many hospitals. Both of these when
properly administered add much to quality care.
Patients can be removed to these units as soon
as practical and relieve the emergency area of
this often long-continued type of emergency care.

The presence of an emergency department
committee made up of the chief of each of the
major services, the administration and the super-
vising nurse of the emergency service with the
function of making policies assures in many ways
improved quality of care within the unit. This
committee should have regular interval meetings
on certain types of cases and problems which ap-

pear from time to time. With good leadership
and free discussion the committee will tend to
improve the care of the emergency service.

CONCLUSION

In half a generation the old “accident room,”
largely for “charity” and injured persons, has de-
veloped into an emergency department, the
community medical center for all types of care,
in all walks of life, in many places. The public
looks to the hospital as the community medical
center and this means that both administration
and medical staff have new responsibilities in
making certain that competent care with suitable
supplies is furnished. Almost every institution is
finding that the area occupied by its emergency
service must be enlarged to cope with its in-
creasing use.

All of the above considerations will make
quality care easier within the emergency area
department. No one of these will result in quality
care, but when present collectively within the
emergency department it is evident that the ad-
ministrative and physician staff is interested and
good quality care will most likely be the end re-
sult. ***

Cleveland Clinic Building (38732)

REFERENCES

1. Berjen, Richard P.: Legal Aspects of Emergency
Departments, Emergency Departments, American
Medical Association, pp. 109-113, 1966.

2. Kennedy, Robert H. : Quality of Care in Emergency
Departments, Emergency Departments, American
Medical Association, pp. 1 17-120, 1966.

3. Bulletin of Joint Commission on Accreditation of
Elospitals, Bulletin # 37 (December) 1964.

4. Kennedy, Robert H.: Guidelines for an Effective
Emergency Department, Hospitals 37:101-116 (June
16) 1963.

5. Seifert, Vernon D.: and Johnstone, J. Stanley: Meet-
ing the Emergency Department Crisis, Hospitals 40:
55-59 (Nov. 1 ) 1966.

6. Shortliffe, Ernest C.: Emergency Departments, Hos-
pitals 36:48-50 (Nov. 1) 1962.

7. Johnson, Charles F.: Three Physicians Provide Con-
tinuous Emergency Coverage, Hospitals 42:93-94
(June 1) 1968.

8. Emergency Room Errors: A Menace to Most At-
tendings, Medical Economics, pp. 112-125 (Aug.
18) 1969.

9. Hospital Emergency Service, U. S. Department of
Health, Education and Welfare, 1963.

10. Facts and Trends on Hospital Outpatient Services,
U. S. Department of Health, Education and Wel-
fare, 1964.

64

JOURNAL MSM A

1

MEETINGS

I I

NATIONAL AND REGIONAL

American Medical Association, Annual Conven-
tion. June 21-25, 1970, Chicago, Clinical Con-
vention, Nov. 29-Dec. 2, 1970, Boston. Ernest
B. Howard. Executive Vice President. 535 N.
Dearborn St., Chicago, 111. 60610.

Southern Medical Association, 64th Annual
Meeting, Nov. 16-19, 1970, Dallas. Mr. Rob-
ert F. Butts, Executive Director, 2601 High-
land Ave., Birmingham, Ala. 35205.

STATE AND LOCAL

Mississippi State Medical Association, 102nd An-
nual Session, May 11-14, 1970, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary, 735
Riverside Drive, Jackson 39216.

Amite-Wilkinson Counties Medical Society, Third
Monday March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson. Suite B-6, Medical Arts Build-
ing. Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port Gib-
son, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday April and First Wednesday
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March. May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018. Gulf-
port. Secretary.

Delta Medical Society, Second Wednesday April
and October. Howard A. Nelson, 308 Fulton
St., Greenwood, Secretary.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-
taurant, Hernando, Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital. Meridian, Secretary.

Adams County Medical Society, First Tues-
day, February, April, June, August, October,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday March, June, September, and De-
cember. James E. Booth. Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October, Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell, 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March,
June, September, and December. A. Robert
Dill. 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day March, June, September, and December.
W. B. White. Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tuesday
January, April, July, and October, 7:00 p.m.,
Old Southern Tea Room, Vicksburg. Martin
E. Hinman. the Street Clinic, Vicksburg, Sec-
retary.

FEBRUARY 1970

65

Radiologic Seminar XCII:
Subclavian Steal Syndrome

T. S. McCAY, M.D.
Jackson, Mississippi

The “subclavian steal” syndrome was first
reported by Cantorini in the Italian literature in
1960. In 1961 Reivich and his co-workers wrote
about this condition in the American literature.
Basically, the disease is the result of stenosis
or occlusion of a subclavian artery proximal to
origin of the vertebral artery with reversal of
blood flow in the ipsilateral vertebral artery. On
the right side, occlusion of the innominate ar-
tery may produce the same condition. Lesions of
the left subclavian artery are, however, more
common than these of the right subclavian and
innominate combined. Following development
of stenosis or occlusion of these arteries, a major
portion of the collateral blood supply to the af-
fected subclavian artery may then come about
by a siphoning effect from the basilar arterial
circulation by way of the vertebral artery, which
may lead to a variety of central nervous sys-
tem ischemic symptoms.

It should be mentioned that not all patients
with occlusive disease of the proximal subclavian
arteries develop “steal” symptoms. While the
principal source of collateral circulation in these
patients is vertebrovertebral, other pathways in-
cluding external carotid-vertebral, external carot-
id-thyrocervical. external carotid-costocervical,
inferior thyroid and internal thoracic may pro-
vide sufficient blood supply around the occlusion

Sponsored by the Mississippi Radiological Society.

From the Department of Radiology, St. Dominic-Jack-
son Memorial Hospital.

to reduce the drain from intracranial arterial
blood supply. Furthermore, the extent of cen-
tral nervous system symptoms will obviously
depend upon the anatomical arrangement of
the intracranial circulation, and presence or ab-
sence of intracranial atherosclerotic disease.

Symptomatology in patients with stenosis or
occlusion of the proximal subclavian artery may
then be related to the central nervous system, or
may be that of peripheral arterial insufficiency
in the involved extremity, or may be a combina-
tion of both. In a report of fourteen cases by
Bryant and Spencer in 1966, seven cases had
ischemic symptoms of the upper extremity only,
three had vertebral-basilar insufficiency only, and
four had combined symptoms. Heidrich and
Bayer state: (1) 45 per cent have cerebral symp-
toms only; (2) 40 per cent have cerebral and
arm symptoms; (3) 10 per cent have arm symp-
toms only; (4) 6 per cent have no symptoms.

Central nervous system symptoms in order of
decreasing frequency are: (1) dizziness; (2)

headache; (3) visual deficits; (4) syncope; (5)
paresis of one or more extremities; (6) ataxia;
(7) aphasia; (8) facial paralysis; (9) insomnia.
Symptoms resulting from peripheral ischemia are,
in order of decreasing frequency: (1) paresthes-
ias; (2) weakness; (3) coldness; (4) fatigue dur-
ing activity; (5) rest pain; (6) paleness or
cyanosis; (7) pain during activity. The most
commonly encountered physical finding is a
significantly lowered blood pressure in the in-

66

JOURNAL MSM A

Figure 1. Film obtained IV2 seconds after begin-
ning of injection of contrast media. Note occluded
stump of left subclavian artery ( open arrow), nor-
mally opacified right vertebral artery ( closed arrow),
and lack of opacification of left vertebral artery.

volved extremity when the disease is unilateral.
Symptoms are frequently progressive over a pe-
riod of months to years.

Arteriography is the radiographic procedure em-
ployed to demonstrate the stenosed or occluded
vessels, and serial films obtained following intra-
arterial injection of contrast media will show
retrograde opacification of the involved vertebral
artery when a “steal” is present. Generally, a
retrograde aortic arch study is the most suitable
approach for evaluation of these cases.

The presented films are from an aortic arch
study done on a patient with subclavian steal
symptoms. Following pressure injection of con-
trast media into the aortic arch serial films were
obtained at the rate of two per second. The
initial films demonstrated occlusion of the left
proximal subclavian artery, a normal left carotid
artery, and normal right brachiocephalic arteries.
Subsequent films showed retrograde opacification
of the left vertebral artery with delayed filling of
the left distal subclavian artery.

In conclusion, it should be stated that since

Figure 2. Film obtained 4 seconds after start of
injection of contrast media. Note delayed retrograde
filling of left vertebral artery (closed arrow) and de-
layed filling of left distal subclavian artery ( open
arrow).

most patients with the subclavian steal syndrome
are potentially curable by appropriate recon-
structive vascular surgery, correct and early diag-
nosis is extremely important.

969 Lakeland Drive (39216)

BIBLIOGRAPHY

1. Reivich. M., Holling, H. E., Roberts, B., and Toole,
J. F.: Reversal of Blood Flow Through Vertebral
Artery and Its Effect on Cerebral Circulation, New
England J. Med. 265:878-885, 1961.

2. Bryant, Lester R., and Spencer, Frank C.: Occlusive
Disease of Subclavian Artery, J.A.M.A. 196:123-128.

1966.

3. Steinberg, Israel, and Halpern, Mordecai: Roentgen
Manifestations of the Subclavian Steal Syndrome, Am.
J. Roentgenol. & Rad. Therapy 90:528-531, 1963.

4. Fischer, Martin J., and Mattey, William E.: The Sub-
clavian Steal Syndrome, Am. J. Roentgenol. & Rad.
Therapy 90:532-534, 1963.

5. Ashby, Robert N.; Karras, B. G., and Cannon, A. H.:
Clinical and Roentgenographic Aspects of the Sub-
clavian Steal Syndrome, Am. J. Roentgenol. & Rad.
Therapy 90:535-545, 1963.

6. Heidrich, H., and Bayer, O.: Symptomatology of the
Subclavian Steal Syndrome. Angiology 20:406-413,
1969.

FEBRUARY 1970

67

The President Speaking

‘Best Part of the Job’

JAMES L. ROYALS, M.D.

Jackson, Mississippi

One of the pleasures that the president of the state medical as-
sociation enjoys during his term of office is visiting the com-
ponent societies within the state. This has been a particularly re-
warding experience. It presents the opportunity to renew old
friendships, and visiting and talking with physicians in their own
communities brings a deeper understanding of their problems.
Many of our physicians, especially those in the smaller rural com-
munities, face a tremendous demand for their services. It is in
these areas that the shortage of physicians is most acute.

It seems only a short time ago that the four-year medical school
at the University of Mississippi graduated its first class. Yet it
has been highly effective in supplying well-trained physicians to
our state. This is apparent everywhere one goes, and it is with
pride that I observe these hundreds of young physicians meeting
with excellence their responsibilities to society and rapidly becom-
ing the leaders of medicine in Mississippi.

Mississippi has many problems, most of which cannot be solved
immediately; but, with continued effort on the part of multiple
hundreds of dedicated people, these problems will be met, and
excellent medical care will be brought to all of our people. ***

68

JOURNAL MSM A

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI. NUMBER 2
February 1970

Medicredit: Delivery
System in AMA's Image

I

With all its wealth, the United States “has
financial limits as to what it can undertake.”
These are the words of the American Medical
Association spoken to the Congress in propound-
ing its health care plan for the nation, suggest-
ing that we will do well to maintain a realistic
perspective about the bottomless pit of spending
tax funds.

AMA has laid Medicredit on the table, call-
ing it “universal in scope, voluntary in nature,
and realistic in terms of total program costs.”
The concept is tax-related, bearing some resem-
blance to the idea of a negative income tax.

Medicredit would abolish Medicaid, but Medi-
care for those over 65 would remain and, indeed,
be crocheted into the new plan. The indigent
would have the same coverage as the well-
heeled who participated. In a nutshell, Medi-
credit would give the option of recovering part
or all of the cost of comprehensive voluntary
health insurance. The amount recoverable would
relate to total tax liability.

Under the plan, you couldn't tell a pauper from
a millionaire unless you saw the tax returns, and

in theory, each would receive the same high qual-
ity of services, according to AMA spokesmen.
Like Shakespeare's quality of mercy. Medicredit
is not strained.

II

The AMA income tax credit plan deals with
tax liability, the amount owed in taxes, not in de-
ductions, such as may now be claimed for health
care expenditures. So allowable amounts for ap-
plication to the purchase of health insurance or
prepayment coverage comes off the tax-due total
on a dollar-for-dollar basis.

The basic concept recognizes that the popula-
tion of the United States may be divided into
three well-defined categories with respect to
health insurance purchasing power:

— Those with essentially no capacity to pay,

— Those with a capacity to pay a portion of
the cost, and

— Those with a reasonably full capacity to pay.

For the first group which would include bene-
ficiaries presently under Medicaid, the plan
would provide the comprehensive coverage with-
out expense or contribution on their part. For
individuals or families with a total tax liability of

FEBRUARY 1970

69

EDITORIALS / Continued

IV

$300 or less for any year, the program would be
theirs for the asking.

A taxpayer with a liability of $500, an inter-
mediate range, would receive 70 per cent of the
cost of his coverage, and so on up a graduated
scale of diminishing government support to the
individual with more than $1,300 owed to Uncle
Sam. He would get the minimum credit of 10 per
cent.

The IRS would fulfill a more humane role
than that in which it is ordinarily cast by issuing
certificates which would be honored against
health insurance or prepayment coverage costs,
in cases where the taxpayer asks for one. The
more affluent would simply furnish evidence of
the insurance purchase and take the difference
off the check submitted with the return.

Ill

To assure uniformity in comprehensive cover-
age, each carrier would be registered with an ap-
propriate agency of the state. The contents of the
insurance package, the range of benefits, would
have to pass muster before the state agency and
would include three parts:

— Part I would furnish a minimum of 60 days
of inpatient hospital services, paid in full after
an initial deductible of $50. Emergency room
and outpatient services would be paid at a rate
of 80 per cent through the first $500.

— Part II would furnish medical services
wherever and whenever needed, payable at 80
per cent through the first $500.

— Part III, a supplemental and optional por-
tion, would provide prescription drugs with a
$50 annual deductible, additional days of hospital
care with a 20 per cent co-pay clause, cost of blood
in excess of three pints, and other personal
health services on written orders of a physician,
also under a 20 per cent patient co-pay require-
ment.

Under the proposed plan, a carrier is defined
as a voluntary association, corporation, partner-
ship, or other nongovernmental organization
which offers a health benefits insurance plan. The
entire program would be supervised by an 11-
member Health Insurance Advisory Board made
up of the Secretary of HEW, the Commissioner of
IRS, and nine public members. This body would
set standards for quality, establish guides for
state insurance departments in registering carriers,
and work out utilization review minimums.

Among the widely varying ideas advanced by
equally varying colors of philosophy, all who
would remake the care delivery system in their
own image seem to agree on the utter necessity
for the insurance mechanism. Without the in-
surance companies, the Blue plans, and state
medical associations, almost no public care pro-
gram could or would be successful. AMA says
that Medicare would “have been an administra-
tive shambles” without the carriers and Blues.

This clearly implies, as the AMA asserts, that
there must be a strengthening and further in-
volvement of the private sector in all care pro-
grams. Medicredit as introduced by AMA is a
basic concept which envisions further refine-
ments, extensions, improvement, and innova-
tions, but not on a crash basis.

The socioeconomic side of health care has
been nearly ripped to shreds by radical replace-
ment, rapid innovation, and sudden shift of fi-
nancial responsibility during the past two decades.
AMA says that Medicredit would halt this sense-
less rush to confusion by providing a basis for
orderly, logical development. “The shortcomings
of our system, whatever they may be,” AMA

"Eight million and one . . . eight million and two
. . . eight million and . .

70

JOURNAL MSMA

declares, “stem from the rapid relatively uncon-
trolled growth of medical technology, the stag-
gering increase in demand, and the American
compulsion to experiment, innovate, and im-
provise in an atmosphere of freedom of enter-
prise and competition in the marketplace.”

Not everybody will agree that Medicredit is
the answer or even the appropriate direction.
But most understand that one way or another,
the decade of the 70’s may well witness a national
health program. To this extent, it is pertinent
that medical organization is in the forefront with
a credible proposal, however presently imper-
fect.

Within the decade, every level of medical
organization will address itself to the crucial
issue of the shape and form of the delivery sys-
tem as they must. Or it will be remade in some-
body else’s image. — R.B.K.

Additives: HEW,
FDA, MSG, LD50

Total immunity from the hazards of our en-
vironment would be most desirable, but it is an
unattainable ideal. This to say that there simply
cannot be fatality-free transportation, accident-
free homes, or absolutely harmless effects of
what we eat and drink. But fervent pursuit of
this goal is implicit in the recent findings and
edicts of the FDA and HEW.

Within the past few months, we have had the
flaps over cyclamates, monosodium glutamate,
and most recently, paprika in meat. Now, this is
the job of FDA, and time was at the turn of the
century when our foods and potables were some-
thing less than 99.44 per cent pure.

But questions are being raised by reputable
scientists as to methodology employed in reach-
ing some of the conclusions as to the dangers of
food additives. So great has the gap become that
FDA has been shaken up from top to bottom,
and it is no secret that the recently removed
commissioner. Dr. Herbert Ley, disagreed with
his superiors in HEW over the monosodium
glutamate issue.

A few have even gone so far as to say that
experimental doses of additives in laboratory
animals, say in the case of the cyclamates which
were the equivalent of an adult’s drinking 700
cyclamate-sweetened soft drinks in one day, real-
ly doesn’t prove the point.

In the instance of MSG, the acute oral LD-o

in rats was 13.3 to 19.9 g/Kg, admittedly a good
bit more than we use in the clam chowder.
Other toxicity tests in lab animals for MSG con-
sisted of injections.

Any scientist can assert that we know little
enough about how our food, drink, drugs, and
water affect us. Yet, the whole of mankind is
doing pretty well in expanded numbers and
longevity. The search for truth in this critical
area must be no less objective and rational than
the search for truth elsewhere. Above all, there
must be no political capital made from a tenuous
or even improbable conclusion.

It seems only logical to foster diversified re-
search and scientific colloquy on the additives,
because if these work for nuclear physics, the
same techniques will also work for flavor en-
hancers in our hamburgers. And it is an unneces-
sary postscript to observe that legally sold and
taxed tobacco is a little more toxic than a few
grams of artificial sweetener. Don’t we really
need to realign these perspectives? — R.B.K.

Data Show
Appendectomy Is Safe

Nobody argues that appendicitis isn’t a serious
surgical condition, but removal of the offending,
diseased tissue has become a pretty safe procedure.
Actuaries of the Metropolitan Life Insurance
Co. have reported detailed studies of appendi-
citis made for the decade 1956-66 and a special
study for 1967. Results are impressive.

The mortality rate for appendicitis in 1967 was
0.8 per 100,000 which is figuratively about as
safe as taking aspirin. In that year, there were
1,500 deaths resulting from the condition, but a
majority of the fatalities occurred after the onset
of peritonitis or perforation. In fact, the greater
the age, the higher the mortality, bringing into
the picture what every physician knows: The
greater frequency of complications resulting from
chronic cardiovascular, respiratory, and diges-
tive system disorders.

Female patients undergoing appendectomy en-
joy a lower mortality rate and shorter hospital
stays than male patients, but women have a
higher incidence of surgery. The rate is 1.9 per
1,000 females against 1.5 per 1,000 males. On a
basis of deaths per 100,000 cases, the female
mortality rate was 0.6, while the rate for males
hit 1.0, still a most favorable figure.

7 1

FEBRUARY 1970

EDITORIALS / Continued

A study of hospitals in Virginia during 1 956-
60 showed that 19 deaths from appendicitis oc-
curred, and all but one were in the group where
perforation had occurred prior to admission.

Nine out of 10 patients admitted for appendi-
citis undergo surgery, the study says, and the
mean hospital stay was 6.5 days. This breaks out
to means of 7.2 days for males and 5.8 days for
females. Incidence of the condition is almost
twice as high among the age group 17-24 and
lowest in the 45-64 bracket. Incidence drops
down to an almost insignificant 0.4 per 100,000
for women over age 45. Average duration of
illness, combining time in the hospital and con-
valescence, was 34.0 days for males and 37.9
days for females. The youngsters under age 24
were ill for only a little over three weeks.

The progressively better experience reflected
in the study underscores concomitant advances
in surgical technique and anesthesia, the growing
effectiveness of antibiotics, and better hospital
care. — R.B.K.

The Agony and the
Ecstasy of Taxes

The Tax Reform and Relief Act of 1969 af-
fects physicians, their practice organization, and
medical societies in many ways. In a touch and
go situation, President Nixon figuratively held
his nose and signed the act into law, realizing as
any astute politician would that he didn’t have the
votes in Congress to sustain his veto.

The AMA-supported Fannin Amendment
knocked out the provision that no individual
could realize more benefit under a professional
corporation than he could under Keogh which,
in reality, extends the tenuous life of professional
corporations for a year. But professional corpo-
rations organized under Subchapter S of the
Internal Revenue Code (which are taxed in a
manner similar to partnerships) are bound to
limits of Keogh or $2,500 per year per partici-
pant. This limitation applies to tax years begin-
ning in 1970.

Retirement benefits under Social Security are
increased 15 per cent without change in the tax
rate. The latter is rhetorical, however, since the
existing escalation timetable was built into the
law in 1965. In brief, taxation was already
there for the so-called increase.

If you own an oil well, there’s bad news, what
with the mineral depletion allowance reduced to
22 per cent from the historic 27.5 per cent
level. Availability of the 25 per cent capital
gains advantage has been drastically reduced,
but you'll still have to hang onto eligible assets
for six months before selling to avoid taxation
as regular income.

By 1973, personal exemptions will get a $750
credit over the present $600, and for the Texas
rich, you can now give charity up to 50 per
cent of adjusted gross income. The surcharge is
slashed by half to 5 per cent and will be wiped
out altogether with fiscal 1971.

Mandatory reporting of payments to physi-
cians of $600 or more annually by health insur-
ance carriers and Blue Shield was deleted, but
IRS has issued regulations requiring such re-
porting. Generally, insurance companies and the
Blue plans have ignored this requirement which
has actually been a regulation under the Internal
Revenue Code since 1954.

Unrelated income of tax-exempt organizations
will be taxed, meaning that AMA and all state
medical associations will pay federal taxes on
medical journal advertising. This will clobber

"I’m putting you on this vegetable diet because
‘ man cannot live by bread alone.’ ”

72

JOURNAL MSMA

AMA which already has $4 million in “back
taxes” pending.

The tax bill is a sort of garbled step toward
equity, but by no means does it achieve it. The
net result is a tax revenue loss. In the meanwhile,
every individual and corporate tax situation must
be carefully re-examined, because if the big
print gives it to you. there may be some fine
print to take it away. — R.B.K.

Work and Play OTV
Can Be Dangerous

We Southerners sometimes get the feeling that
everything which can happen to us eventually
does, but there is one growing problem — medical,
legal, and economic — which we will not likely
face: The menace of the snowmobile, most pop-
ular of the new generation of overland terrain
vehicles.

The OTV is just about the newest transporta-
tion form on the American scene. It is part of
the family of dune buggies, swamp buggies, and
the all-purpose OTV we are beginning to see in
the South, the pint-sized rowboat with six over-
size, low-pressure tires. The snowmobile is a
small, heavy affair, usually seating two persons
in tandem, with skis forward and a chain track
at the rear for driving power. It is about as
close to a motorcycle as you can get with snow.

The snowmobile has become extremely popu-
lar for work and play in a short time. There
are 100.000 of the powerful, fast bugs in Michi-
gan. and estimates are that some 600,000 have
been purchased in the northeast and Canadian
border states. About 25 companies make them,
and they say that the boom is just beginning.
Sales to date have been made mainly in small
towns and rural areas.

The American Mutual Insurance Alliance re-
ports that the go-anywhere-in-snow capability of
the noisy bugs harasses farmers besides break-
ing down fences. Snowmobile looters have ran-
sacked closed resort cabins, and northern rail-
roads complain of the fast vehicles using space
between rails with expected resulting fatal col-
lisions with trains.

U. S. Customs officials say that snowmobiling
Canadians ignore official entry points as they
zip across the border to bars and restaurants on
the American side. Conservationists are con-
cerned about snowmobile pursuit of game which
is dooming the preserves.

But toll of human life is the big problem. The

most frequent fatal accident is crashing through
thin ice with drowning. Second most fatal mis-
hap is striking fixed objects. Alcohol-charged
snowmobilers are as much of a menace off the
road as the drunk driver is on the highways,
taking into consideration the variation in traffic
density for the two types of transportation.

Insurance claims from snowmobile accidents
are resulting in higher premiums for nearly all
casualty coverage where the bugs abound. There
is a challenge for safety and common sense in
the picture, because the vehicle has great poten-
tial for work and recreation. But take comfort:
You will not be rammed by a reckless snow-
mobile driver as you go home tonight in the
sunny South. — R.B.K.

Februcuy 11, 1970

SEMINAR ON LOW BACK PAIN

University Medical Center, Jackson
February 11, 1970. beginning at 8:30 a.m.

Sponsored by The University of Mississippi
School of Medicine Postgraduate Education
Committee, the Department of Medicine and
the Department of Surgery, Division of Or-
thopedics, with the support of the Voca-
tional Rehabilitation Services Administra-
tion. U. S. Department of Health, Educa-
tion and Welfare

Participants:

Stewart Agras, M.D., professor of psychiatry and
chairman of the department, The University of
Mississippi School of Medicine
Hanes H. Brindley, M.D., Temple, Texas
Robert Currier, M.D.. professor of medicine, The
University of Mississippi School of Medicine
James D. Hardy, M.D., professor of surgery and
chairman of the department, The University of
Mississippi School of Medicine
Bernard S. Patrick, M.D., associate professor of
neurosurgery. The University of Mississippi
School of Medicine

Joseph N. Schaeffer. M.D., professor of physical
medicine and rehabilitation and chairman of
the department, Wayne State University School
of Medicine, and director. Rehabilitation Insti-
tute, Detroit, Michigan

73

FEBRUARY 1970

POSTGRADUATE / Continued

Henry A. Thiede, M.D., professor of obstetrics
and gynecology and chairman of the depart-
ment, The University of Mississippi School of
Medicine

W. Lamar Weems, M.D., associate professor of
surgery and chief, division of urology, The
University of Mississippi School of Medicine

Wednesday Morning

Anatomy of the Low Back
Dr. Brindley

As the Gynecologist Sees It
Dr. Thiede

The View of the Urologist
Dr. Weems

The General Surgeon’s Concern
Dr. Hardy

The Neurosurgeon’s Approach
Dr. Patrick

Wednesday Afternoon

Physical Examination and Orthopedic
Management
Dr. Currier

From the Psychiatric Standpoint
Dr. Agras

Conservative Management of Low Back
Pain

Dr. Schaeffer
General Discussion
March 2-6, 1970

NEPHROLOGY INTENSIVE COURSE

University Medical Center, Jackson

March 2, 3, 4, 5, 6, 1970, beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Participant:

John D. Bower, M.D., assistant professor of medi-
cine, The University of Mississippi School of
Medicine, and director, artificial kidney unit,
The University of Mississippi Medical Center

This one-week intensive course, the sixth
in the 1969-70 series, is a clinically-oriented
course emphasizing the reversible and treat-
able forms of kidney disease. The manage-

ment of acute kidney failure will be presented
in depth. The management of pyelonephritis,
fluid and electrolyte problems, and acid base
balance will also be covered and the partici-
pants will become familiar with hemodialysis
in clinical radiology. Registration is limited to
five state physicians from the class of 20 en-
rolled in the Mississippi Postgraduate Institute
in the Medical Sciences.

CIRCUIT COURSES
Southern Circuit

Hattiesburg — February 5 — Session 2
Forrest General Hospital, 6:30 p.m.
Laurel — March 12— -Session 3

Laurel Country Club, 6:30 p.m.
Gulfport — February 4 — Session 2

Gulfport Memorial Hospital, 6:30 p.m.
Biloxi — March 4 — Session 3

Bay-Waveland Yacht Club, 6:30 p.m.
Session 2 — Diagnosis and Management of
Malignant Skin Lesions
Dermatologic Approach, Dr. James G.
Thompson

Surgical Approach, Dr. James H. Hendrix
Session 3 — Current Approach to Tetanus
Prophylaxis and Treatment, Dr. Ray-
mond Martin

Diagnosis and Management of Hyper-
thyroidism, Dr. J. Manning Hudson

Eastern Circuit

Columbus — February 24 — Session 2

Lowndes General Hospital, 6:30 p.m.
Session 2 — Respiratory Failure: Current

Methods of Management, Dr. Boyd
Shaw

Surgical Management of Emphysema, Dr.
William Fain

Meridian — March 3 — Session 1

Northwood Country Club, 6:30 p.m.
Session 1 — Carcinoma of the Cervix

Radiologic Approach, Dr. Bernard Hick-
man

Surgical Approach, Dr. Richard Boronow

Southwestern Circuit

Natchez — February 17 — Session 2

Jefferson Davis Memorial Hospital,

6:30 p.m.

Session 2 — Hyperthyroidism

Medical Management, Dr. Herbert Lang-
ford

Surgical Management, Dr. Harvey Johns-
ton

74

JOURNAL MSM A

FUTURE CALENDAR
February 4, 1970

Circuit Course, Biloxi
February 5

Circuit Course, Hattiesburg
February 9-13

Radiology Intensive Course
February 11

Seminar on Back Pain
February 17

Circuit Course, Natchez
February 24

Circuit Course, Columbus
March 2-6

Renal Disease Intensive Course
March 4

Circuit Course, Biloxi
March 6

Renal Disease Seminar
March 12

Circuit Course, Hattiesburg
March 16-20

Cardiology Intensive Course

Stroke Intensive Course

April 1-3

Cardiovascular Seminar
April 7

Circuit Course, McComb
April 16

Mississippi Thoracic Society
April 21

Circuit Course, Columbus
May 11-14

Mississippi State Medical Association

Spencer Barnes of Columbus has been elected
vice president of the Columbus-Lowndes Cham-
ber of Commerce and Industrial Foundation.

Jim Barnett and J. P. Crawford and their
wives of Brookhaven recently returned from the
MSMA-sponsored tour to the Island of Majorca
off Spain.

James E. Booth of Eupora has been elected
president of the Clarke Memorial College Alumni
Association. Dr. Booth is also a trustee of this
Baptist institution.

D. L. Clippinger of Hazlehurst has been ele-
vated to the presidency of the Hazlehurst Cham-
ber of Commerce. The ceremony took place at
the organization’s Christmas banquet.

J. P. Culpepper, Jr., of Hattiesburg has been
named chairman of the committee on education
of the Forrest County Arthritis Chapter.

Melvin Ehrich of Clarksdale and Durward
Blakey of Jackson were participants in “Stop
Measles Sunday” in Coahoma County. The two
physicians immunized 2,948 children against
red measles.

Ben P. Folk, Blanche Lockard and Robert
Ireland, all of Jackson, were on the program of
the Tenth Annual Institute of Pastoral Care of
the 111 at the Mississippi Baptist Hospital in
Jackson in mid-January.

Harry C. Frye, Jr.; Warren A. Hiatt; and
Henry L. Lewis, III of Magnolia announce the
removal of their offices from Beacham Hospital
to the Magnolia Clinic on Magnolia Street.

Wendell N. Gilbert, a native of Wayne Coun-
ty, opened offices for the general practice of
medicine in Taylorsville in January. Dr. Gilbert
recently graduated from the University of Mis-
sissippi School of Medicine at Jackson and in-
terned at St. Elizabeth Medical Center in Dayton,
Ohio.

George Green was recently honored by the
Benoit and Scott communities for his services
to them over the past 22 years. The Benoit
Lions Club served as host of the ceremonies
during which the honoree and his wife were

FEBRUARY 1970

75

PERSONALS / Continued

presented a matched set of luggage and a check
for a vacation trip.

Jerry Kaplan has been appointed to the staff
of the Marshall County Hospital in Holly Springs.
The surgeon holds membership on the medical
staffs of Baptist, Methodist, and St. Joseph Hos-
pitals in Memphis.

Andy E. Kirk of Starkville is locating his of-
fices temporarily at Felix Long Hospital. Dr.
Kirk was formerly in practice with LeRoy
Howell.

Stanley C. Russell of Jackson was recently
appointed Acting Chief, Psychiatry Service, at
the Jackson VA Center.

Richard C. Schmidt of Biloxi has associated
with the Schmidt Clinic at 137 Lameuse Street
for the practice of pediatrics. Dr. Schmidt, a
graduate of Tulane Medical School, is the son of
Dr. and Mrs. Harry J. Schmidt, Sr.

Frank K. Tatum of Tupelo has announced his
retirement from the practice of medicine on the
advice of his physician. Dr. Tatum has been serv-
ing as Director of the Lee-Itawamba County
Health Departments and has long been active in
his state association. Most recently he was elected
Secretary of the Preventive Medicine Section of
MSMA at the 101st annual session in May of
1969. He has also announced his resignation
from this position.

Elbert A. White, III, of Corinth has not moved
to Booneville but has established hospital priv-
ileges there at the Northeast Mississippi Hospital.

William L. Wood, Jr., of Tupelo demonstrated
the techniques of external heart and mouth to
mouth resuscitation at a recent District 14 Heart
Association meeting in Corinth.

Green, James Clifton, Tupelo. M.D., Tu-
lane University School of Medicine, New
Orleans, La., 1934; postgraduate study, New Post-
Graduate Hospital, 1938; died Dec. 3, 1969,
age 59.

McDougal, Luther Love, Jr., Tupelo.
M.D., Vanderbilt University School of Med-
cine, Nashville, Tenn., 1933; interned Vanderbilt
Hospital, Nashville, one year; postgraduate work,

Williard Parker, 1934; Babies Hospital, 1934;
R. I. Hospital, 1935-1937; Providence Lying-In
Hospital, 1937; died Dec. 12, 1969, age 60.

Suttle, Thomas Cleveland, Louisville. M.D.,
Memphis Hospital Medical College, Memphis,
Tenn., 1911; interned Matty Hersee Hospital,
Meridian, three months; residency, Chicago
EENT Hospital, Chicago, 111., seven months;
died Dec. 18, 1969, age 84.

The following physician has been elected to
membership by his component medical society in
the Mississippi State Medical Association and
the American Medical Association.

Chavez, Carlos Manuel, Jackson. Born Lima,
Peru, Dec. 25, 1932; M.D., San Fernando Faculty
of Medicine, Lima, Peru, 1956; interned Hospital
Regional de Tacna, Lima, Peru, one year; vascular
surgery residency, Massachusetts General Hos-
pital, Boston, 1960-61; cardiovascular surgery
residency, Methodist Hospital, Houston, Texas,
1961-62; cardiovascular surgery fellowship. Uni-
versity Medical Center, Jackson, Miss., 1963-64;
general surgery senior resident, University Medical
Center, Jackson, Miss., 1964-65; Hektoen Medal
(AMA) awardee; assistant professor of surgery,
UMC; elected Sept. 2, 1969 by Central Medical
Society.

Sirs: It was my pleasure and good fortune to
have the privilege of attending a seminar con-
cerning rubella at Mississippi State University
recently.

Dr. Louis Z. Cooper’s presentation was the
most practical and understandable lecture it has
been my privilege to hear. In Mississippi we
spend thousands of dollars to care for individ-
uals who have preventable defects but a negli-
gible amount to determine the susceptibles and
protect them, thereby protecting their offspring
from these preventable causes — rubella being one
of the most serious.

H. C. Ricks, M.D., Member
Miss. State Board of Health
Jackson, Miss. 39205

76

JOURNAL MSMA

Book Reviews

Introduction to Medical Science. By Clara
Gene Young and James D. Barger, M.D. 275
pages with illustration and appendix. St. Louis:
The C. V. Mosbv Company, 1969. $7.95.

The present use and the advocated greater
utilization of paramedical personnel in the care
of the sick and injured has prompted the authors,
one a medical writer and the other a practicing
pathologist, to write a volume to fill in the gaps
in knowledge about the causes of diseases and
their effects on individual organs and the body
as a whole.

The first chapter is devoted to an introduc-
tion which along with the preface not only ex-
plains the reason for the book, but also relates in-
struction on the use of the volume and what to
look for in one’s search for knowledge about dis-
eases.

The style of preparation is designed so that
the reader can be a self teacher. Chapters two
through fifteen are written to include a step-by-
step method of self examination. These chapters
are devoted to basic concepts of disease causa-
tive factors. This, in fact, emphasizes the title of
of the book, Introduction to Medical Science.

In order to understand diseases the authors
take the reader or student through the answers
to the following questions: Is it an inflammation,
allergy, trauma, tumor, congenital defect, me-
chanical obstruction, circulatory disturbance, met-
abolic or nutritional disorder, or the result of in-
fection?

In each of the chapters referred to above
the format includes representative diseases un-
der each heading. However, in the make-up of
the remaining chapters the style is changed and
the content is restricted to the selected diseases
of the various anatomical and physiological sys-
tems. Needless to say, it would take a many
volumed encyclopedia to catalogue and describe
all the diseases with which a medical assistant
might have to deal during her days of service to
the doctor and his patients.

The appendix is divided into two parts: A.

the responses to the step-by-step exercises; and
B, a cataloguing of infectious diseases.

My overall evaluation of the book is that it is
well written, portions of which would be benefi-
cial to medical secretaries, and the entire vol-
ume to nurse medical assistants. It is apparent
from its contents that individuals who have some
knowledge of anatomy and physiology would
receive the most benefit from their use and study
of the text. It should be useful in courses de-
signed to train medical assistants.

Richard G. Burman, M.D.

Physiology of the Gastrointestinal Tract. By
E. Clinton Texter, Jr., et al. 262 pages with 106
illustrations. St. Louis: The C. V. Mosby Com-
pany, 1988. $10.75.

This easily readable small book is well edited
and attempts to delineate the areas of physiologic
knowledge most relevant to medical practice. The
author covers the subject under four major head-
ings: splanchnic circulation, motor mechanism,
secretion, and absorption. Most of the material
is presented and discussed in a clear manner.
There are, however, rather confusing sections
for a book directed to medical students as its
author claims.

The chapter on gastrointestinal motility is well
covered and up-to-date, but too much emphasis
is given to some aspects. For example, the sec-
tion of “electrical phenomena at the level of the
cell membrane” is very difficult to understand
without previous knowledge of physics and mathe-
matics. Some other aspects very relevant to gas-
trointestinal physiology are practically neglected,
such as liver physiology; perhaps because it is a
very large subject to be considered in a small book
such as this.

Although there are some negative aspects in
this book, the overall evaluation is positive. It is
a useful addition to the few already in existence
covering the difficult problems in gastrointestinal
physiology. The references are good and up-to-
date.

Lidio O. Mora, M.D.

FEBRUARY 1970

77

ORGANIZATION / Continued

Baptist Hospital
Elects 1970 Officers

Dr. Noel C. Womack, Jr., has been elected
president of the Medical Staff of Mississippi Bap-
tist Hospital of Jackson for the calendar year
1970. He succeeds Dr. James M. Packer.

President-elect for 1970 is Dr. Albert L.
Meena, who served as vice president of the staff
in 1969.

The new vice president is Dr. Robert P. Hen-
derson, who served in 1969 as a member of both
the Isotope Committee and the Utilization Re-
view Committee.

Secretary of the Medical Staff for 1970 is Dr.
H. C. Ethridge, a member of the Tissue Com-
mittee, who succeeds Dr. William S. Cook.

MSBH Warns About
Animal Bites, Rabies

Certain important points regarding bites by
non-domestic animals should be reviewed. Each
animal bite situation must be evaluated individ-
ually regarding the need for antirabies treatment.

Any wild carnivore (such as the skunk,
weasel, fox, coyote, raccoon, bobcat, or badger)
and certain other species, such as the bat, may
harbor rabies. The danger of keeping wild carni-
vores as pets should be emphasized; particularly
young animals since they are susceptible to rabies
and could have acquired it from the mother who
died of the disease. Bites by these species must
be considered a rabies exposure until proven
otherwise. Clinical signs of rabies in some spe-
cies of wild animals, such as bats, may not be re-
liable and, therefore, instead of being held for
observation, the animal should be killed at once
and the brain examined, using the fluorescent
rabies antibody (FRA) test. On the other hand,
bites of rodents, including gophers, squirrels,
chipmunks, rats, mice, hamsters, and guinea
pigs rarely, if ever, call for specific rabies prophy-
laxis. Unwarranted treatment must be avoided
just as stringently as indicated treatment should
be given.

Immediate and thorough cleansing of bite
wounds is the most important preventive mea-
sure. Following this, combined treatment with

rabies vaccine and anti-rabies hyperimmune
serum is recommended as soon as possible for
(1) All exposures classified as severe (head,
neck, face or finger bites: puncture wounds; mul-
tiple bites); (2) All Bites by rabid wild ani-
mals (combined treatment even for mild ex-
posures by domestic carnivores may also be used,
and is recommended by some authorities); (3)
All Bites by wild carnivores and bats suspected
(unprovoked attack, abnormal behavior) of be-
ing rabid pending results of laboratory tests. If
the FRA test is negative, vaccine treatment should
then be discontinued. When indicated, the anti-
rabies hyperimmune serum should be used re-
gardless of the interval between exposure and
initiation of treatment. It should not be assumed
that it is “too late” to administer serum.

Pfizer Comments on
FDA Recall

The FDA has announced its decision to order
recalled from the market oxytetracycline capsules,
produced by eight manufacturers, because of
FDA’s determination that those products are of
questionable value medically.

While Pfizer initially provided to FDA the re-
sults of its blood level studies on a number of
oxytetracycline products, and made its expertise
on this important drug available to FDA, in the
end it was FDA's task to conduct its own studies
and to decide what action to take in this highly
complicated area.

This is another scientifically documented in-
stance which demonstrates emphatically that
drugs of the same generic name are not neces-
sarily equivalent therapeutically.

The antibiotic oxytetracycline was discovered
by Pfizer in 1949, and over the years has been
manufactured and distributed throughout the
world under the trade name “Terramycin.” Since
the expiration of the Pfizer patent in 1967, oxy-
tetracycline capsules have been manufactured
and distributed in the United States by a num-
ber of other companies under the generic name,
oxytetracycline, or other brand names.

Pfizer’s oxytetracycline capsules, marketed un-
der the brand name “Terramycin,” are not af-
fected by the FDA action, and remain on the
market. Indeed, Pfizer’s Terramycin capsules have
been designated by FDA as the standard for
blood levels that must be met in order for oxy-
tetracycline products to be considered as satis-
factory for certification by FDA.

78

JOURNAL MSMA

Formal Opening of New Headquarters
Addition Set by Trustees for Feb. 25

Formal opening of the new addition to the as-
sociation’s Central Office Headquarters Building
has been slated for Feb. 25, according to Drs.
James L. Royals of Jackson, president, and Mai
S. Riddell, Jr., of Winona, chairman of the Board
of Trustees. The MSMA leaders said that open
house for members and guests is scheduled
from 5 until 7 that evening.

Dr. Riddell, who also served as chairman of
the Building Committee, said that all Trustees
will be present for the occasion. Other Build-
ing Committee members are Drs. J. T. Davis
of Corinth and William O. Barnett of Jackson.

“The addition fulfills a need first recognized
by the House of Delegates in 1967," Dr. Royals
said. “Growth of association activities and ser-

Final touches are added on the interior of the
headquarters building addition as painters, left, finish
office entrance. Right is stairwell to rear entrance
opening on new and expanded parking area. Lower

vices to our members and the public was far be-
yond our expectations in the decade of the 1960’s,
and the addition will help us fulfill this vital mis-
sion.

“Beyond this,” Dr. Royals added, “the build-
ing has been a fortunate and valuable invest-
ment for the association, appreciating in value
during the 14 years we have occupied it.”

The construction project was reaffirmed by
the House of Delegates for a second time in
1968. and last year, design was completed and
bids invited just before the 101st Annual Ses-
sion. The House approved the project and fi-
nancing in 1969, urging that the new and needed
space be provided as soon as feasible.

Also provided with the addition is vastly ex-

level has service facilities and mail room. Open door
in right photo shows part of new membership de-
partment office.

FEBRUARY 1970

79

ORGANIZATION / Continued

panded off-street parking, almost triple the orig-
inal area, Drs. Royals and Riddell said. The
existing building has been repainted and re-
paired where necessary concomitantly with the
new construction.

W. R. Bob Henry, A. I. A., of Jackson is the
architect, and Priester Construction Co., also
of Jackson, was the general contractor.

The project was begun in late spring of 1969 and
completed in January 1970 on schedule. Basic
construction cost was $100,693 under the gen-
eral contract.

Drs. Royals and Riddell said that the an-
nouncement constituted “a warm and cordial in-
vitation to members of the association, their
ladies, and Auxiliary members for the Feb. 18
opening and open house.” Invitations are being
sent to nonmedical friends of the association, in-
cluding state and community leadership.

The officials said that brief ribbon-cutting cere-
monies will be conducted at 5 o’clock in the after-
noon on Feb. 25 after which members and guests
may tour and inspect the addition and existing
building. The open house will continue until 7
o’clock in the evening.

Drs. Royals and Riddell said that the Woman’s
Auxiliary will be furnished a permanent office
in the expanded headquarters building. The de-
cision was made by the Board of Trustees in
December, they added.

Mrs. Louise C. Lehmann of Natchez, state
Auxiliary president, recently inspecting the new
office said that “this is the first time in our history
that we have had a headquarters office of our
own.” She expressed satisfaction over the decision
of the Board.

Progress on the project has been reported to
the membership monthly in the Journal. Addi-
tionally, the Building Committee and Board of
Trustees have closely monitored each phase of
the construction.

IRS Sends Card
Explaining New 1040

Each of the 18 million taxpayers in the United
States who filed the now discontinued card 1040 A
form last year will receive a post card explaining
the change to the new consolidated 1040 form.
Mr. J. G. Martin, Jr., District Director of In-
ternal Revenue for Mississippi, said that the
post card should have already been received by

the 167,000 Mississippi taxpayers who filed
1040A’s last year.

In general the post card states that this year
all taxpayers will receive a larger, more complete
tax package which includes the one-page basic
1040 and additonal pages or schedules, which
may or may not be used, according to the tax-
payer’s needs.

Past 1040A users will find that except for a
few lines, the new 1040 asks for the same in-
formation as the old card form and that they will
probably not need to fill out more than one
sheet to make out their returns if the standard
deduction is claimed.

In the past, taxpayers who used the 1040 A
could not take advantage of certain tax credits
or exclusions and could not itemize their deduc-
tions. A principal reason for making the change
to the new form is to enable taxpayers to take
full advantage of the tax benefits the law pro-
vides.

State Board of
Health Commended

The State Board of Health and its employees
in the state health department and the county
health departments have been cited by the United
States Public Health Service for “their remark-
able devotion to duty throughout the health
emergency created by Hurricane Camille, Au-
gust 1969.”

The commendation came last week when a
certificate was presented to State Health Officer
Hugh B. Cottrell in a special ceremony at the
State Board of Health Building in Jackson.

Dr. Henry C. Huntley, Director of the Division
of Emergency Health Services, U. S. Public Health
Service, brought the certificate of appreciation
from Washington, D. C.

Lt. Gov. Charles Sullivan made the presenta-
tion. Presiding was Dr. Frank J. Morgan, Jr.,
Assistant State Health Officer.

Describing as “incomprehensible” the magni-
tude of the disaster wrought by Camille, Lt.
Gov. Sullivan told public health personnel:

“We were confronted with what could have be-
come a very critical health situation. . . . And
then you responded. You made the place safe.
You provided an environment in which we could
work. There is no way we could estimate the
value of the contribution you made.”

While the work after Hurricane Camille was
“one significant occasion,” said Lt. Gov. Sullivan,

80

JOURNAL MSMA

“it's not really so different, because you've demon-
strated your dedication over the years.”

In response. Dr. Cottrell said the measure of the
effectiveness of the work of the public health
workers was the fact that no major epidemic was
spawned in the wake of the hurricane.

The state health officer said a total of 235
nurses, sanitarians, engineers, doctors, technicians
and other key personnel from the state health de-
partment and the county health departments
throughout the state moved into the stricken area
while many others contributed to the emergency
effort in a supportive role.

Dr. Cottrell also expressed appreciation for the
support the United States Public Health Service
gave to the State Board of Health during the
emergency operation — -in both personnel and ma-
terial.

Dr. Huntley, commenting on the cooperation
between USPHS and the State Board of Health,
said it was “one of the best examples of federal-
state cooperation I’m aware of.”

Drug Dependence
Published By NIMH

A new publication has been inaugurated by
the National Institute of Mental Health to facili-
tate the dissemination and exchange of informa-
tion in the field of drug dependence.

The new quarterly journal. Drug Dependence,
is prepared jointly by the Institute’s Division of
Narcotic Addiction and Drug Abuse and its Na-
tional Clearinghouse for Mental Health Informa-
tion to answer a recognized need for a profession-
al publication in this area. The journal will
serve scientists of many disciplines, legislators,
lawyers, teachers, students, and others.

Drug Dependence will present abstracts, origi-
nal articles by professionals in the field, and an
occasional reprint to give an historical perspec-
tive to the problem of drug abuse.

Individuals or institutions involved or inter-
ested in the field of drug addiction or related
areas may be placed on the mailing list for Drug
Dependence by writing to the National Clearing-
house for Mental Health Information, National
Institute of Mental Health, 5454 Wisconsin Ave-
nue, Chevy Chase, Maryland 20015.

Copies of Drug Dependence can be purchased
for 50 cents each from the Superintendent of
Documents, U. S. Government Printing Office,
Washington, D. C. 20402.

Intensive Care Unit
Opens at Alabama

The very fact that the staff in the Medical
Intensive Care Unit is always working under
crisis conditions makes it an appealing place to
work for many dedicated registered nurses.

“You have to be devoted to working with the
extremely ill patient, or you just won’t be able
to keep up the pace,” explained Miss Peggy
Duke, head nurse for MICU.

The opening last month of the UAB Medical
Center’s new Medical Intensive Care Unit
(MICU) for seriously ill patients emphasizes
Alabama’s need for more RN’s who have spe-
cialized training.

“Nurses in units such as this learn to function
in a way which is different from the traditional
role of nursing,” said unit director Dr. Durwood
Bradley, who is also chief of staff for University
of Alabama Hospitals and Clinics.

“Nurses here must learn to act independently
in crisis situations, and many times they have
to make effective judgments quickly,” he said.

The state’s newest hospital suite for intensive
patient care is an eight-bed section of Univer-
sity Hospital's 15th floor.

In this concentrated area, highly skilled per-
sonnel utilize medicine's latest equipment for the
handling of acute medical emergency develop-
ments.

Patients are selected for care in the unit on
the basis of need. Once they pass the critical
period of illness, they are moved into other
areas of the hospital to make room for more
seriously ill patients.

The unit opened soon after the adjacent Myo-
cardial Infarction Research Unit began to accept
patients with heart attacks. The two facilities
share some common equipment and personnel,
but the nursing staffs operate separately.

At least one resident physician is assigned to
the MICU at all times.

Patients brought to MICU are acutely ill, and
cases range from emphysema and respiratory fail-
ure to shock and internal bleeding.

Emphasizing the country’s general need for
personnel trained in the techniques of intensive
care, Dr. Bradley noted, “An intensive care unit
is totally dependent upon the quality of its nurs-
ing care. That makes it imperative that we
continue our active involvement in the training
of highly qualified nurse specialists.”

8 1

FEBRUARY 1970

ORGANIZATION / Continued

John Sanders Gets
Yugoslavian Fellowship

John R. Sanders, of Jackson and Greenwood, a
third year medical student at the University of
Mississippi School of Medicine, has been awarded
one of 14 AAMC/PHS International Fellowships
by the Health Services and Mental Health Ad-
ministration of the U. S. Public Health Service.

Sanders, whose wife Cindy is MSMA Member-
ship Director, will be based in Belgrade, Yugo-
slavia, Feb. 9-April 18, 1970.

The award is made “to provide Fellows with
training in medical care techniques and health
service organization unique to Yugoslavia, and
thereby improve their knowledge of and famil-
iarity with various problems of medical diagnosis
and treatment, and with specific problems re-
lating to public health, medical care, and the
structure of medicine in Yugoslavia.”

During the ten week fellowship, the American
students will be under the direction of Professor
Dr. Jovan Cekic of the Institute of Public Health.
Republic of Serbia; and the Faculty of Medicine,
University of Belgrade.

MSMA President James L. Royals congratulates
medical student John Sanders on receiving an
AAMC/PHS fellowship to Yugoslavia.

The fellowship grant includes round-trip jet
fare and a stipend adequate to cover room,
board, and minor expenses while in Yugoslavia.

Orientation and briefing for the medical students
will be held in Washington, D. C. on Feb. 5.

The students will be exposed to the people in
their homes, villages and towns. It will not be a
standard clinical clerkship in a large hospital,
but actual interaction with the people of Yugo-
slavia, commented Russell C. Mills, Ph.D., pro-
gram director.

For each two U. S. medical students, there
will be a Yugoslavian medical student, who
has completed his fifth and last year of the medi-
cal curriculum, to act as interpreter and col-
laborator in contacts with patients.

Yugoslavia lies on the northwestern portion of
the Balkan peninsula and is bordered by Italy,
Austria, Hungary, Romania, Bulgaria, Albania,
and Greece. Part of the country is a fertile plain
and the rest is mountainous.

The coastal areas have hot dry summers and
mild rainy winters while inland there is a mod-
erate continental climate. Belgrade lies on ap-
proximately the same parallel as Boston.

Unlike the U. S. where doctors are in great
demand, hundreds of Yugoslavian medical gradu-
ates each year are unable to find jobs.

Sanders, currently president of the junior class
at UMC, is the first Mississippi student to take
part in the Yugoslavian program although other
UMC students have participated in AAMC fel-
lowships to Israel and Thailand.

Florida Offers
Hypertension Course

The departments of pediatrics, medicine, pathol-
ogy, surgery, physiology, ophthalmology, and
radiology of the University of Florida College of
Medicine will hold a seminar on hypertension
Feb. 27-28.

This symposium is an attempt to present a
comprehensive review of the most significant
new knowledge in the area of hypertension
which affects nearly 17 million Americans. Spe-
cial emphasis will be given to early diagnosis,
treatment and the long term care of the hyper-
tensive patient.

Dr. Irvine H. Page and Dr. Wadi N. Suki will
participate as guest faculty. Other speakers will
be University of Florida faculty members.

Tuition for the course is $50.00. Inquiries
should be addressed to the Division of Postgradu-
ate Education, J. Hillis Miller Health Center,
Box 758, Gainesville, Florida 32601.

82

JOURNAL MSMA

Hasn’t
he skipper
iad enough
incitement
or one day?

,iunson,
ssages in
t ■section
Christ-
hich is
of the
' the

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at Vir-
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ir the
rg 3t
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nd
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mier

4 n lUon Yacht Runs Aground

Owner Breaks Arm W he ^ ^ The ^

Schuyler, Oct. 31. ^Juredarm had to isUtoated

CovesviUe incurved * rock damage to the >a

icbf

hr the patient who has been
rough an accident, the worry
id anxiety following the
ishap may actually heighten
e perception of pain. This is
hy there’s a classic Va grain
idative dose of phenobarbital
Phenaphen with Codeine—

• take the nervous "edge” off,
d the rest of the formula can
Dntrol the pain more effectively.

3S!vfSy,/l'H'DO BINS

Phenaphen' with Codeine

Phenaphen with Codeine Nos. 2, 3, or 4 contains: Phenobarbital {Va g r.) , 1 6.2
mg. (warning: may be habit forming); Aspirin (21/2 gr.), 162.0 mg.; Phenacetin
(3 gr.), 194.0 mg.; Hyoscyamine sulfate, 0.031 mg.; Codeine Phosphate, Va
gr. (No. 2), Vz gr. (No. 3), or 1 gr. (No. 4) (warning: may be habit forming).

The compound analgesic that calms instead of caffeinates

Indications: Phenaphen with Codeine provides relief in severer grades of
pain, on low codeine dosage, with minimal possibility of side effects. Its use
frequently makes unnecessary the use of addicting narcotics. Contraindica-
tions: Hypersensitivity to any of the components. Precautions: As with all
phenacetin-containing products excessive or prolonged use should be
avoided. Side effects: Side effects are uncommon, although nausea, con-
stipation and drowsiness may occur. Dosage: Phenaphen No. 2 and No. 3 —
1 or 2 capsules every 3 to 4 hours as needed; Phenaphen No. 4 — 1 capsule
every 3 to 4 hours as needed. For further details see product literature.

ORGANIZATION / Continued

Medicare Increases
Hospital Deductibles

‘The overall cost of living keeps going up, and
hospital costs are no exceptions,” said J. G. Artz,
District Manager of the Columbus, Miss. Social
Security Office.

Because of the increase in the cost of the aver-
age hospital stay, social security Medicare bene-
ficiaries will have an increase in their hospital
deductibles.

Beginning Jan. 1, 1970, the social security
beneficiary will pay the first $52.00 of their hos-
pital costs rather than $44.00 as in the past. In
the event the beneficiary stays more than 60
days, then his share of the costs will be $13.00
per day for all days over 60 days up to 90
days. Before Jan. 1, 1970, this was $11.00
per day.

Artz also said that Medicare beneficiaries will
have to pay an increase in the extended care
facility deductible. If the beneficiary is in the
extended care unit more than 20 days, the new
rate will be $6.50 for the 21st through the 100th
day. Before Jan. 1 , this was $5.50.

Medical Textbook on
Cardiology Published

A new edition of “The Heart,” a medical
textbook with nearly 1,700 pages and more than
1 ,000 illustrations, has been published under
the editorship of Drs. J. Willis Hurst and R. Bruce
Logue of the Emory University School of Medi-
cine.

The book is described as “a complete treatise
of medical knowledge of the heart and blood
vessels designed to bridge the gap between basic
science and clinical practice. It was written to
help physicians as they care for patients.”

Published by McGraw-Hill Book Co., New
York, the book has 103 chapters.

Dr. Hurst is professor and chairman of the
department of medicine, Emory University School
of Medicine, and Dr. Logue is a professor of
medicine. The two physicians — widely known
heart specialists — wrote much of the book in ad-
dition to serving as senior editors.

The first edition of the book appeared in
1966 and represented five years of work. The

new (second) edition is larger by more than
400 pages than the previous book and is one of
the most heavily illustrated books in existence.

The new edition was written with the editorial
assistance of Dr. Robert C. Schlant, professor of
medicine; Dr. Nanette K. Wenger, associate pro-
fessor of medicine, and Mrs. Ruth Strange, all of
the department of medicine, Emory Univer-
sity School of Medicine.

Eighty-four American and British physicians
contributed articles to the book. Nineteen of
these contributors were from the Emory medical
school in the specialties of internal medicine, pedi-
atrics, radiology, and surgery.

Dr. Arthur P. Richardson, dean of the Emory
University School of Medicine, said of the new
book:

“When the first edition appeared four years
ago, it attracted national and international at-
tention, and today this new and enlarged edition
is perhaps destined to become the leading treatise
on cardiovascular diseases.”

The new book will be available in either one
or two volumes.

Ole Miss
Grows Marijuana

Dr. Norman J. Doorenbos (second from left),
chairman of the department of pharmacognosy at
the University of Mississippi School of Pharmacy,
holds a section of locally grown marijuana which
will he used in research aimed at answering questions
arising from use of the drug. The Ole Miss drug
garden was opened to tours this week and among
visitors were Dr. Carl Sloan of Philadelphia (left),
Dr. Cherie Friedman of Oxford and Dr. Charles W .
Hartman (right), dean of the School of Pharmacy at
Ole Miss.

84

JOURNAL MSM A

Dr. L.W. Long
Receives ICS Award

Dr. Lawrence W. Long, Jackson surgeon, was
recently presented a bronze placque by the In-
ternational College of Surgeons. Dr. Harold O.
Hallstrand of Miami, incoming president of the
U. S. section, made the presentation at the
banquet for installation of officers of the U. S.
section in Chicago.

The placque’s inscription reads “By unani-
mous acclamation at our 1969 meeting we ex-
tend to you our sincere appreciation for your years
of devoted and untiring service to the General
Surgical Group of the International College of
Surgeons.” It is signed by Dr. Lowell R. Smith,
chairman. General Surgical Group.

Others present at the presentation ceremony
were Dr. Philip Thorek of Chicago, ICS vice
president, and Dr. Mike O’Herron, outgoing pres-
ident of the U. S. section, ICS.

Dr. Long is currently serving as treasurer of
the college and is chairman of the publications
committee of his state medical association.

Dr. Harold Hallstrand, at right, incoming presi-
dent of the U. S. section, ICS, presents a bronze
placque of appreciation to Dr. Lawrence W. Long at
the college’s installation ceremonies in Chicago.

Miss, and La. Internists
Plan Scientific Meet

Specialists in internal medicine in Mississippi
and Louisiana will hold a scientific meeting
Feb. 20-21, 1970 at the Broadwater Beach
Hotel, Biloxi, Miss. The meeting is sponsored by
the American College of Physicians (ACP).

The meeting is a regional scientific-educational
meeting of the College and is aimed at helping
internists practicing in these states keep informed
of new developments in the basic and clinical
sciences that affect their practices. A total of
39 are being held during the 1969-1970 aca-
demic year for the College’s 15,000 members.
The College has been holding them annually
since 1930.

The meeting is under the general direction of
Dr. Wesley W. Lake, Sr., Pass Christian, Miss.,
ACP Governor for Mississippi, assisted by Dr.
A. Seldon Mann, New Orleans, La., ACP Gov-
ernor for Louisiana. Dr. Lake is Assistant Clinical
Professor of Medicine at Tulane University
School of Medicine and Dr. Mann is Professor
of Clinical Medicine at Tulane.

Mound Park Hospital
Schedules Courses

The Mound Park Hospital Foundation, with
the joint sponsorship of the Department of Medi-
cal Education of the Bayfront Medical Center,
the University of Florida College of Medicine,
Pinellas County Medical Society, and the Florida
Academy of General Practice, has announced
two postgraduate courses in early spring.

On April 16-18, “The Pulse of Laboratory
Medicine” is scheduled. This symposium has been
approved for 18 hours of credit by the American
Academy of General Practice. Fee is $100.00.

A symposium on “Pediatric and Adolescent
Psychiatry” will be held May 21-23. This course
has been approved for 18 accredited hours by the
AAGP. Fee is $50.00.

These courses will be completely comprehen-
sive and designed to more fully orient practition-
ers in the various fields of medicine and surgery
to the problems of patient care. The Founda-
tion reserves the right to limit registration.

All classes, meetings, and clinical conferences
will be held at the Tides Hotel and Bath Club,
Redington Beach (St. Petersburg), Fla., and
though informal, will be consistent with the high-
est standards of teaching practice.

The teaching faculties will be composed of
selected guest lecturers and qualified staff mem-
bers.

FEBRUARY 1970

85

ORGANIZATION / Continued

Mississippi's Children
Graduate From U.T.

Judy Wheat Wood and Chad Wood, daugh-
ter-in-law and son of Dr. and Mrs. William
Martin Wood of Gulfport, simultaneously re-
ceived their M.D. degrees in the December
graduation exercises at the University of Ten-
nessee.

Dr. Judy Wood, formerly of Shelbyville, Tenn.,
is a B.A. Cum Laude graduate of Transylvania
of Kentucky. Dr. Chad Wood of Gulfport is a
B.A. Cum Laude graduate of the University of
Mississippi.

The husband and wife team are both mem-
bers of Alpha Omega Alpha, the honorary medi-
cal society. Judy served as secretary-treasurer
of the graduating class. Chad received the “Out-
standing Student” award presented by the U.T.
department of psychiatry.

Both new physicians have six month fellow-
ships at U.T. while awaiting internship confirma-
tions via the matching program in March.

Dr. Chad’s father graduated in the Decem-
ber class at U.T. 23 years ago and held the po-
sition of secretary-treasurer of the class.

Redbook Publishes
New Mother’s Guide

Redbook Magazine has recently published a
handbook for new mothers to be used as a help-
ful guide during the first year of a baby’s life.

“Redbook’s Young Mother” is an attractively
done paperback booklet containing advice and
information on various phases of the maternal
life. Such articles as baby’s food, bathing the
baby, the new mother’s health, and helping
baby learn to talk are included and even a few
quick recipes for busy mothers are listed.

Articles are written by authorities in the vari-
ous fields, including a dentist and several physi-
cians.

A reference guide to baby’s health is found
at the back of the booklet and gives information
on first aid, common ailments of infancy, im-
munization schedules and accident prevention.

The booklet is available for $.75 from Read-
ers’ Service Bureau, P. O. Box 461, Old Chelsea
Station, New York, N. Y. 10011.

1970 Directory
Has Been Mailed

The 1970 Mississippi Directory of Physicians
has been distributed to every member of the
association. The mailing was completed during
the first week of January, the announcement
said.

The new publication is a 96-page reference
source of medical licentiates in the state. It also
lists career federal medical officers of the Veter-
ans Administration and U. S. Public Health
Services as well as residents and interns in AMA-
accredited training institutions.

Two divisions respectively list every physi-
cian alphabetically and by county. The gen-
eral alphabetical division contains addresses
and ZIP codes. Membership and practice ac-
tivity status is keyed for each physician listed,
the announcement continued.

The association also publishes a Monthly Di-
rectory Supplement listing all changes of address
and status, new physicians, removals, and deaths.
The Directory is provided as a service to mem-
bers and sold for $5 per copy postpaid to oth-
ers. The Supplement is available only on sub-
scription for $6 per year.

Blood Bank Association
Holds Annual Meeting

The 12th annual meeting of the South Cen-
tral Association of Blood Banks will be held
in Houston on March 12-14, 1970, at the Rice
Hotel. Any member of the medical professions,
administrative or technical personnel, and oth-
ers interested in blood banking are invited to
register.

On Thursday morning, March 12, an Admin-
istrative Workshop will be presented. Dr. E. Rich-
ard Halden, Jr., Medical Director, Carter Blood
Center, Fort Worth, will preside.

On Thursday afternoon, March 12, the SCABB
Committee on Technical Workshop will present
a seminar which will feature a panel of distin-
guished experts. Case histories will be presented
by the seminar moderator and a seminar manual
will be provided.

Among the outstanding speakers who will par-
ticipate in the program are William Pollock.
Ph.D., of Ortho Research Foundation, Raritan,
New Jersey; Dr. Carlos Ehrich of the New York
Blood Center; and Peter Issett of Spectra Bi-
ologicals, New York City.

86

JOURNAL MSMA

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535-9

ORGANIZATION / Continued

MSBH Reports on
Family Planning Project

“Acceptance of the services of the Family
Planning Project has been rewarding to all the
workers in the clinics,” said Dr. William E. Rieck-
en, director of a State Board of Health compre-
hensive family planning project in Hinds, Rankin,
and Madison counties that got underway the
middle of June.

Financed by a grant of $66,000 from the Chil-
dren's Bureau, the project purposes to expand
the family planning program in the county health
departments. The grant covers the remainder of
this calendar year. An application has been
made for an 18-month extension which would
add Warren County.

“Cooperation among the three county health
departments, the University of Mississippi Medi-
cal Center, the Community Services Association
(OEO), and our project has been excellent,”
said Dr. Riecken.

Medical services for the clinics, currently set
up at 11 different sites, are provided by eight
residents in the UMC department of obstetrics
and gynecology and Dr. Helen Barnes, through
contact with the University Medical Center. Dr.
Barnes became medical director of the project
Oct. 13. With her appointment, the project staff
became complete.

The supervisory nurse, who joined the proj-
ect in June, is Mrs. Patricia A. Atkinson. A
graduate of the Tennessee Baptist Memorial
School of Nursing, she has had five years of ex-
perience as a public health nurse in Bolivar
and Hinds counties and recently obtained a Bach-
elor of Science degree in nursing from the Uni-
versity of Mississippi School of Nursing.

Rounding out the project staff are two clerks
and two health aides. In addition to assisting in
the clinics, the aides make home visits to follow-
up patients and contact clubs and neighborhood
groups to spread information about the family
planning program. Plans are to add an additional
nurse, clerk, and health aide to the staff during
the new budget period.

As soon as the Community Services Associ-
ation initiates family planning services in the city
of Jackson, the MSBH project will concentrate
efforts chiefly on the county areas.

In order to better coordinate patient services
among the local programs concerned with family

planning. Dr. Riecken said the MSBH project
proposes to set up and maintain a Central Fam-
ily Planning Register for Hinds County.

“A single family planning record is being de-
veloped which will have copies to be sent to
each cooperating program so that a patient can
be seen in any of the clinics at any time and a
record of her services will be available,” said
Dr. Riecken.

As of Nov. 1, a total of 730 patients had been
admitted to the project, 110 of which had never
been in a family planning program. Approxi-
mately one third of the family planning recip-
ients of the health department programs had
changed over to the project program. After in-
stituting family planning practices at postpartum
clinics, the Hinds-Rankin Maternity and Infant
Care Project refers patients to the FP Project for
follow-up services.

New Orleans Graduate
Medical Assembly Meets

The thirty-third annual meeting of The New
Orleans Graduate Medical Assembly will be held
March 2, 3, 4, 5, 1970, headquarters at The
Roosevelt Hotel.

Nineteen outstanding guest speakers will par-
ticipate and their presentations will be of interest
to both specialists and general practitioners. The
program will include fifty informative discussions
on many topics of current medical interest, in ad-
dition to a clinicopathologic conference, symposia,
medical motion pictures, round-table luncheons,
and technical exhibits. This program is accept-
able for twenty-two (22) prescribed hours and
nine (9) elective hours by the American Academy
of General Practice.

An interesting and enjoyable program of en-
tertainment for visiting ladies has also been
planned.

Of special interest will be a one-day pre-As-
sembly symposium scheduled for Sunday, March
1 on “The Price of Medical Progress” presented
by noted authorities. This symposium is accept-
able for six (6) prescribed hours by the Ameri-
can Academy of General Practice. This session
will be strictly limited to physicians and their
wives.

For further information, contact Secretary,
Room 1538, 1430 Tulane Avenue, New Orleans,
Louisiana 701 12.

88

JOURNAL MSM A

before and after surgery

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Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

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ORGANIZATION / Continued

Business Consulting
Becomes Profession

Business consulting for doctors — specialist firms
concentrating on professional practice and fi-
nancial management — is rapidly becoming a pro-
fession in the precise sense of the term. General
business consultants have been on the scene
since the early 1900’s. Professional business con-
sulting is newer, having become an identifiable
profession in the 1920’s and 1930’s, and having
grown rapidly since World War II.

The field is becoming a mature profession in
four ways.

First, it is a recognized specialty. It is not gen-
eral business consulting, where services are of-
fered to all types of businesses. Neither is it
vertically specialized, as are the law and account-
ing, in which a specific service is offered to all
comers. Instead, professional business consul-
tants offer a variety of expertise (from account-
ing to office operations to tax know-how to in-
vestment planning) to a specialized group. They
know the business of managing medical and den-
tal practices.

Second, it has developed its own body of liter-
ature and knowledge. This knowledge ranges
from internal office procedures to setting up
group practices. Much of it has been developed
through the group’s national organization, the
Society of Professional Business Consultants
(SPBC).

Third, it has its own code of ethics, again de-
veloped through SPBC. This code specifies the
training and experience needed, requires that
qualified consultants work at their profession full-
time, and prohibits their acceptance of commis-
sions from suppliers. They are truly professional
advisors.

Fourth, the profession has its own national so-
ciety, SPBC, which establishes and enforces stan-
dards of conduct, encourages the development
of a literature medical-dental economics, enables
members to exchange information and ideas on
a professional basis.

To get more information and obtain a roster
of qualified consultants in your own area, write
the Society of Professional Business Consultants,
221 North LaSalle Street, Chicago, Illinois 60601.

Yale Medical School
Gets $2 Million Grant

The Commonwealth Fund has announced a
grant of $2 million to Yale University School of
Medicine for a new and far-reaching attack on
the effects of accidental injury — now the lead-
ing cause of death in this country in the first half
of the normal life span.

The grant will enable Yale’s Department of
Surgery, headed by Dr. Jack W. Cole, to launch
a comprehensive program to improve and re-
form prevailing patterns and practices for the
handling of trauma victims.

The grant will also aid the construction of a
major new facility — the Laboratory for Surgery
and Obstetrics and Gynecology — to provide a
permanent base for the trauma program and
house the Department of Surgery. The Fund al-
located the grant equally between the start-up
costs of the trauma program and the related new
facility.

In a statement announcing the grant, Quigg
Newton, President of the Fund, said:

“The magnitude of accidental injury as a na-
tional health problem is underscored in a Na-
tional Academy of Sciences study which re-
vealed that in 1965 accidents killed 107,000
people in the United States, temporarily dis-
abled ten million, and permanently impaired
400,000. Most of those killed or maimed were
under thirty-seven years of age. Thus, aside
from the personal tragedy involved, there was a
large and irreparable loss to society in produc-
tive human talent.

“Although the toll of accidental injury con-
tinues to rise, the problem of the accident vic-
tim has not yet been approached in a compre-
hensive way — that is, from the total spectrum of
coordinated actions, communications systems, and
medical knowledge, techniques, and training re-
quired in the care of the patient from the in-
stant of his accident through his treatment and
rehabilitation.

“The essential purpose of the Yale trauma
program is to pioneer in demonstrating an ap-
proach of this kind. Attainment of this objective
would place Yale in the forefront of the attack
on a grievously neglected national health prob-
lem. Moreover, it would exemplify the poten-
tial of university medical centers to participate
with community institutions and agencies in the
the task of forging effective and efficient systems
of health care.

90

JOURNAL MSMA

Because the Yale trauma program is concen-
trating on the urgent need for action to improve
the chances for the survival and rehabilitation
of accident victims, work on accident prevention,
while recognized as vital, is not being empha-
sized at this time. Even so, as designed by Dr.
Cole, the program will be an exceptionally com-
prehensive effort.

The two other main components of the Yale
trauma program are: (1) social science studies
of injury and its consequences — for example,
the role and effectiveness of social agencies in
dealing with accident victims and their families;
and (2) evaluation of the adequacy of the
legal system in handling accident cases, particu-
larly with respect to medical evidence.

These several efforts will be carried out by a
strong inter-disciplinary team of twenty-one spe-
cialists in surgery, medicine, biochemistry, pa-
thology, sociology, law, and such other areas as
transportation and communications systems. The
team will be under a program director, who will
be aided by a two-man administrative staff.

More than half the three-year financing re-
quired for these faculty and staff positions, for
secretarial support, and for space renovation and
other needs will be provided by the $1 million al-
located by the Commonwealth Fund for the
start-up costs of the trauma program.

The $1 million of the Fund’s grant allocated
for the construction of the new building which
will house the trauma program and the Depart-
ment of Surgery becomes payable as soon as
this part of the grant, combined with funds from
other sources, will enable construction to proceed.

Booster Heart
Systems Unveiled

Four different and completely implantable cir-
culatory assist (“booster heart”) systems, and
calves in which 2 of the systems have been im-
planted, have been unveiled by the National
Heart Institute’s Artificial Heart Program (AHP).
This is the first time that the various electronic,
hydraulic, and thermal components of the sys-
tems have been brought together as complete
functioning systems, although the subsystems had
been tested individually in previously reported
“bench” and animal trials.

The occasion of the unveiling was the presen-
tation of the concurrent developmental efforts
to an advisory group of 6 eminent physicians and

engineers at the Washingtonian Motel and the
Gaithersburg facility of Melpar, Inc., Gaithers-
burg, Md. Members of the ad hoc advisory group
are authorities in the particular areas of scientific
and technological expertise required to develop
the currently reported systems.

In welcoming the advisory committee, Dr.
Theodore Cooper, director of the National Heart
Institute, stated, “The successful combination of
components and their implantation in animals pro-
vides not only a unique opportunity to assess
where we should go from here in this (circula-
tory assistance) aspect of the AHP, but will also
supply scientific keys of great value to our un-
derstanding of problems involved in developing
systems for total heart replacement.”

Dr. Frank Hastings, chief of the AHP, asked
the advisors to submit their individual recom-
mendations at a later date as to what foreseeable
problems must be overcome to realize the full
potential of circulatory assistance. Dr. Hastings
also asked the advisory group to consider, in
view of the usual progressive nature of heart
failure, whether greater emphasis should be
placed at this time on the development of sys-
tems to replace the heart totally rather than to
permanently assist the living heart.

Dr. Hastings emphasized that the systems be-
ing presented are by no means ready for clinical
trials in patients. He said that no special attempts
were made to build long-term reliability into the
components or in their miniaturization beyond
that necessary for insertion into the 200-pound
calves (which have approximately the same cir-
culatory requirements and heart size as adult hu-
mans). Indeed, in an ensuing film depicting the
systems and their implantation, some of the com-
ponents appeared about the size and shape of
bricks. Yet they were inserted easily by the sur-
geons into various recesses of the calf abdominal
cavity. The total weight of each system is about
5 Vi pounds. Furthermore, the implanted systems
have been functioning effectively for up to 6
weeks.

Dr. Hastings said the systems were designed
only to identify problem areas pertaining to the
compatibility of various components with each
other and with the body. Nevertheless, he said,
the attainment is a leap forward toward eventual
clinical use. It is also a splendid example of co-
ordination of the eight contracting firms that de-
signed, tested, assembled, and implanted the 4
systems via the unique (for the biomedical sci-
ences) systems-development approach employed
by the AHP.

FEBRUARY 1970

91

ORGANIZATION / Continued

Dr. Egeberg Calls for
Public, Private Aid

The responsibilities for the health care of the
American people in the 1970s must be shared
by the private and public sectors and neither sec-
tor can go it alone, according to the nation’s sen-
ior medical officer.

“We must develop shared or cooperative ar-
rangements that will best meet our national goal
of high-quality health care for every American at
reasonable cost,” Dr. Roger O. Egeberg, Assist-
ant Secretary for Health and Scientific Affairs,
Department of Health, Education, and Welfare,
said in an address at the annual luncheon of the
Health Insurance Association of America
(HIAA).

The aim of the national administration is to
try to get a “fuller interaction” between private
and public interests so as to solve problems af-
fecting the population generally, the speaker em-
phasized.

“The dialog between the leaders of private
and public health insurance has come a very
long way in two decades,” he continued.

“In many private sessions, at conferences like
this one and at others sponsored by public agen-
cies, I observed a growing desire to be mutually
helpful. This is a good sign; anyone engaged in
the health care business these days can use all
the help he can get.”

Dr. Egeberg listed a number of factors which
he said have brought on and aggravated the
nation’s medical care crisis, including the lag in
construction of out-of-hospital facilities, a chronic
shortage of professional and allied health work-
ers, the escalation in hospital costs, and a rise in
doctors’ fees. He also enumerated the demands on
health services brought on by the Medicare and
Medicaid programs; “inefficient management” of
public programs, contributing to health cost in-
creases; and private plans and public programs
that take “expensive care” of advanced defects
and diseases while neglecting preventive care.

He said that the HEW is asking Congress to
provide more flexibility in health care facility
legislation so as to shift the emphasis from hos-
pital construction to “balanced community sys-
tems of interrelated health facilities. ...”

Redirecting construction funds, Dr. Egeberg
pointed out, reinforces a broader effort directed
toward state and area-wide comprehensive health
planning and health services development.

“The Health Insurance Association of Amer-
ica,” he said, “is to be commended for vigorously
supporting comprehensive health planning. The
fact that over 200 insurance company representa-
tives are involved in the planning process is good
news back home.”

The other major resource, besides facilities,
that must be increased is health manpower, the
HEW official continued. His department is not
only emphasizing physician education and opera-
tional support to medical and dental schools but
is aiming an increasing number of programs to-
ward the education of subprofessionals, he
said.

“It is too soon to predict whether we will lick
the health manpower shortage during the 1970s,
but we certainly mean to reverse the unfavor-
able trends of the 1960s,” he said.

The Medicare program, according to Dr. Ege-
berg, “has no serious structural, administrative,
or management problems, and it performs to the
satisfaction of most beneficiaries and providers,
but there is lots of room for improvement in the
performance of the system.”

There are, he said, defects in the conception
and organization of the Medicaid program. He
added that soon after his appointment at HEW
he joined with Secretary Robert Finch in an-
nouncing a series of administrative actions to al-
leviate “some of the more obvious problems.”

He then summed up what he termed the three
main responsibilities for the health care of the
American people in the 1970s. These, he said,
are: Provision of the required quantity and vari-
ety of health care facilities and health manpow-
er; improvement and expansion of the mecha-
nisms of paying for health care; and the respon-
sibility to make certain that the health money of
the people is spent wisely.

Arteriosclerosis Studied
at AHA Meeting

The results of a survey of research objectives
in arteriosclerosis were reported by National
Heart Institute scientists, Dr. Gardner C. McMil-
lan and Mr. Alan Hough, at the American Heart
Association annual meeting in Dallas.

Of a sample 1,930 grants geared to the study
of arteriosclerosis (AS), the general breakdown
is as follows: 90 per cent of the grants comprised
basic and applied research while 10 per cent cen-
tered on development. Approximately 85 per cent
of the grants were oriented to AS causation and
prevention, 5 per cent to diagnosis, and 10 per
cent to therapy.

92

JOURNAL MSMA

The study revealed similar patterns of research
among various agencies, both governmental and
private, in the United States and Canada. One-
third of the 1,930 grants pertained to lipid (fat)
metabolism and one-sixth to studies on the clot-
ting mechanisms of the blood and how they con-
tribute to arteriosclerotic disease.

Approximately 20 per cent of the research ef-
forts included such categories as multiple theories
of causation, epidemiology, psychosocial studies,
and genetics. Investigations into blood vessel me-
tabolism accounted for 6 per cent while 5 per cent
of the grants involved vascular injury and repair
concepts. Only a fraction of 1 per cent were con-
cerned with plaque hemorrhage or regression of
arteriosclerosis.

The material for the study was drawn at ran-
dom from AS investigations supported by govern-
mental and private agencies in the United States
and Canada during 1966 and 1967. Objectives
of the sample were determined from full research
proposals, abstracts, key words, or project title
analysis.

Dr. McMillan commented, “It is clear that in-
vestigators interested in arteriosclerosis think as
a group that it is most useful to study lipids and
blood clotting mechanisms. Whether the relative
inactivity of some of the other areas of study —
for example, regression studies — represents an
appropriate balance and correlation of research
aims is an interesting matter for the scientific
community to debate.”

Arteriosclerosis is the general scientific name
for a number of diseases of the arteries, includ-
ing hardening of the arteries.

Atherosclerosis is the most common form of
arteriosclerosis, and it affects primarily the larger
arteries of the body. It is a condition in which the
inner layer of the artery wall is thickened and
irregular, and in which there are deposits of fatty
substances on the interior of the artery.

The exact way an artery “hardens” is one of
the major unsolved problems of medical science,
and the subject of hundreds of research studies.
For some reason still not clearly understood, fat-
like substances build up on the inside walls of the
arteries. Gradually they accumulate and form
thick deposits called “plaques.” These deposits
both roughen the artery’s normally smooth inner
lining and narrow the channel for blood flow,
making it more difficult for enough blood to get
through. Making matters worse, the artery also
loses elasticity with age and loses its flexibility.

Every artery throughout the body is subject to
hardening, but the most often and most seriously
affected vessels are the largest arteries, such as
the aorta; the coronary arteries; and the arteries

that feed the brain and kidneys. Arteries may
harden in one part of the body more rapidly
than in other areas.

It is believed that some, but probably not all,
of the fatty substances that build up on the ar-
tery wall come from the blood fats. People with
high concentrations of fat in their blood develop
hardening of the arteries earlier and are more
likely to suffer serious consequences in later
years.

Just what starts the process of hardening of
the arteries is not known.

More than half of all deaths from the various
kinds of heart disease are the consequence of
hardening of the arteries. It is the culprit behind
several of the most familiar afflictions of the
cardiovascular system.

Insurance Executives
Combat Rising Costs

A group of prominent insurance executives
have called on health insurance companies to
shift the emphasis of their policies and programs
in an effort to help combat rising medical costs
and to help make high-quality care available to
all persons.

The executives made their remarks as part of
a panel presentation to the Individual Insurance
Forum conducted by the Health Insurance Asso-
ciation of America at the Sheraton Boston Ho-
tel. Members of the panel were Daniel W. Pet-
tengill, vice president, Aetna Life & Casualty;
William C. White, Jr., vice president, Prudential;
and Howard Ennes, second vice president, Equi-
table Life Assurance Society.

The health care system today is in a condition
of crisis, the panel said, and one that is worsen-
ing. The panel members said the condition has
been brought about by a conjunction of many
forces, including shortages of manpower and fa-
cilities, rapidly rising costs, 21st century medical
technology that is “shackled” to 19th century or-
ganizational patterns, and to the existence of a
“two-class” system of health care which often re-
sults in inferior care, or no care, for the “poor
and the near poor” in the inner cities and rural
areas.

The system of the future, they said, must “shift
the focus of concern from the extraordinary to the
ordinary, emphasizing the prevention of disease,
health maintenance and education, early diagnosis
and treatment.”

FEBRUARY 1970

93

ORGANIZATION / Continued

The panel urged insurers to play a more ac-
tive role in health planning to improve the avail-
ability of health services and facilities.

Insurers can make a significant contribution,
the executives said, by helping to put emphasis
on the use of less costly forms of care.

“We have to reverse the order of priority from
in-patient to out-patient care,” the panel stated.
“The future should see not only more emphasis
on ambulatory care, but new methods of orga-
nizing this type of care.”

The group noted that this approach would re-
quire the creation of community ambulatory care
centers as part of systems to provide “outreach”
services where people actually are as “points of
entry” into the health care system.

“Perhaps a quarter of the surgery now per-
formed in hospitals could be handled in these
centers, as well as much diagnostic testing,” the
panel said.

A variety of other types of service facilities
should be integrated with the ambulatory care
centers, the group said, including such facilities
as convalescent care and rehabilitative units,
home care services and custodial facilities.

Insurers could help by expanding their cover-
ages to meet the costs of such facilities, they
said, adding:

“An immediate need is to make health insur-
ance readily available to cover the cost of care in
these alternative facilities and services. Prefer-
ably this should be on a basis which encourages
their use in place of hospitals wherever appropri-
ate.

“Our companies should review their current
programs and make certain that benefits are ade-
quate in relation to the need for protection, and
comprehensive with regard to health care ser-
vices.”

The group also called on doctors and hos-
pitals to adopt cost-saving techniques such as
out-of-hospital diagnostic tests aimed at cutting
down on the number of days a patient must
spend in the hospital, full hospital operation on
a seven-day-a-week basis, central purchasing of
services and goods, such as laundry and food,
and the acceptance by physicians of stepped-up
development of paramedical personnel.

The latter development, the group noted, will
not only help alleviate the shortages in the medi-
cal care field, but will also offer “hundreds of
thousands of opportunities for people to find so-
cially productive and individually satisfying job
opportunities.”

Bill Proposed to
End Inheritance Tax

The Greeks did have a word for it — the word
was Harpyiai, which translates to snatchers.

The Greek word, subsequently Anglicized to
Harpies is apparently in the opinion of many
Americans synonymous with the inheritance tax
collector.

Congressman Robert Price of Texas, author of
a bill to drive the Harpies away, is now seeking
support of fellow Congressmen to end with what
has been a major cause of mergers, as well as
the liquidation of the family-held farm.

His bill is practically identical in context with
one introduced by Senator Robert Dole of Kan-
sas which was submitted to a nationwide vote by
the National Federation of Independent Business
with an 83 per cent majority supporting the bill.

Under present inheritance, or death tax laws,
when the principal owner of a family, or closely-
held, business approaches the end of his life span,
a crisis results. Knowing on his death the business
will be forced to pay an inheritance tax far in ex-
cess of any existing cash position, and often not
even in line with its earning record, the usual pro-
cedure is to seek a merger to avoid liquidation.

The family head of a family-owned farming
operation faces the same situation, inasmuch as
today’s inflated land and property values are not
at all in line with the profitability of the enter-
prise, whether it be an independent business firm,
or a farming operation.

The bills by Congressman Price and Senator
Dole would permit the value of an estate for in-
heritance tax purposes to be set, at the option of
the executor, either on the basis of the deceased’s
costs, or on the basis of the profit of the enterprise
as revealed by income tax returns.

Congressman Price cites the hypothetical ex-
ample of a family-owned cattle ranch that under
the present system of appraising at today’s in-
flated values would be assessed at $300,000 leav-
ing the inheriting son liable for $1 10,500 in taxes,
according to his computations.

Using this hypothetical example, to further il-
lustrate, the Texas legislator says the actual profit
being realized is only $7,500. Thus, using a rea-
sonable factor for determining value, the estate
should only be valued at $105,000 which would
result in a death tax liability of $22,500.

On top of the Federal death tax, most states
also assess a similar tax, but usually the states will
follow the Federal pattern.

94

JOURNAL MSMA

MPAC

AMPAC

give you IMPACT, doctor!

But make it a mutual impact, doctor, because your PAC
needs you and you need your PAC. Both AMPAC and
each of the 50 state PAC’s are voluntary, nonprofit, un-
incorporated, autonomous groups whose members are
physicians, their wives, and others in allied professions.
Every group is bipartisan, bound by no party label. The
voting record, platform, and program of a candidate —
not his party — is what the PAC considers.

The basic purpose is twofold: To educate in political
affairs and to provide a means through which the physi-
cian-citizen can effectively make his voice heard in the po-
litical arena. MPAC is medically oriented and medically
directed by a 10 member board consisting of nine physi-
cians and a Woman’s Auxiliary representative.

With the elections behind, MPAC is looking ahead to
1970 when there will be a job to do. Make your voice
count by sending your dues today, $10 for MPAC and
$10 for AMPAC. Better send dues for your wife, too-

MISSISSIPPI MEDICAL
POLITICAL ACTION
COMMITTEE

FEBRUARY 1970

95

ORGANIZATION / Continued

Operation of the inheritance tax has and con-
tinues to create many problems which are prob-
ably more middle-class in nature than those of
the very wealthy who have learned to use founda-
tions and other loopholes to escape the full weight
of the tax laws.

Many claim that because in many states ap-
praisers are paid a percentage of the value of the
estate, as well as probate fees being based on this
formula, there is an effort to pad the value of the
estate. A respondent to the Federation survey in
California, a widow with a motel, recently
charged that deliberate padding of her husband’s
estate not only stripped her of all cash, but ne-
cessitated borrowing money at high interest rates
to keep the motel from being liquidated.

Probably because people only die once, legis-
lators who have in the past sought to correct the
death tax situation have experienced difficulty in
obtaining mass support.

When he ran in the California primary for the
United States Senate, Pierre Salinger, former
White House press secretary attacked the Cali-
fornia system of handing out appointments as in-
heritance tax appraisers branding it as a particu-
larly vicious example of awarding profitable po-
litical patronage plums.

Under the Reagan administration an attempt
was made to change the system, but failed to get
legislative approval. This failure was registered
after the present State Controller Hugh Flournoy
requested all estate appraisers voluntarily take an
examination to determine their fitness for the po-
sition. A substantial number refused to take the
test, and of those who did, about half did poorly.

The present inheritance tax laws were enacted
in the motion-laden depression years when men
were selling apples in the streets at a time when a
few heirs and heiresses came into their inherit-
ances which they proceeded to flaunt with world-
wide publicity. Thus, the legislation was to pre-
vent this from happening in the future.

But the result has been that the extremely
wealthy have developed means of escaping the
full impact of the law while the closely-held busi-
ness and the family farm, the backbone of the
middle-class, bears the brunt.

Perhaps the comparison between this situation
and Greek mythology is even more pertinent. In
early ancient mythology Harpies were considered
somewhat semi-beneficial but in the later era of
the Argonautic sagas Harpies had degenerated in-
to foul and loathsome creatures. The inheritance
tax appears to have followed the same course.

Whether or not Congressman Price and Sena-
tor Dole will be able to emulate Calais and Zetes
who drove off the Harpies, remains to be seen.
Not only must they secure support from fellow
legislators, say Federation researchers, but they
must also educate the less knowledgeable that the
inheritance taxes are no longer a “soak the rich”
device, but a powerful destructive force of the
middle-class backbone.

I

Artificial Placentation
System Developed

New and clinically promising information
about the profound circulatory changes that oc-
cur soon after birth — changes that enable the
essentially aquatic fetus to adapt to a terrestial,
air-breathing mode of existence — was recently
reported by scientists of the National Institutes
of Health to the American Heart Association
annual meeting in Dallas, Texas.

The studies were conducted by Drs. Warren
M. Zapol, Theodor Kolobow, and Gerald G.
Vurek, Ph.D., of the National Heart Institute’s
Laboratory of Technical Development, John L.
Doppman, Clinical Center Diagnostic Radiology
Department, and Joseph E. Pierce, D.V.M., NHI
Laboratory of Kidney and Electrolyte Metabolism.

Their x-ray motion picture studies of blood
flow patterns in isolated non-breathing fetal
lambs supported by an “artificial placenta” show
that the fetal circulatory pattern can be changed
to the adult type of circulation in a matter of min-
utes— and reversed just as quickly even after
several hours — by manipulating the levels of
oxygen in the blood.

In these studies, premature and term fetal
lambs were removed from ewes by caesarian sec-
tion and maintained in a physiologically stable
state for hours by the artificial placentation sys-
tem developed by the NHI scientists. Several of
the animals were delivered (“born”) after pro-
longed periods on the artificial placenta with long
term survival.

A key component of the artificial placenta-
tion system is an artificial lung, the spiral coil
membrane blood oxygenator, that provided total
respiratory support for the lambs via their blood.
The unique design features of this lung permit
gentle, efficient, and prolonged oxygenation of
the blood with precise regulation of blood oxy-
gen levels and blood flow.

The system also includes a temperature-con-
trolled fluid bath (“artificial womb”) in which

96

JOURNAL MSMA

the fetus is submerged; specially designed can-
nulas for joining umbilical vessels to the blood
tubes of the system; and a modified roller pump
to “milk” blood forward gently through the sys-
tem and back to the lamb. (See attached back-
ground statement for more detailed descriptions
of system components.)

With this system and the injection of radi-
opaque dye for the visualization of fetal circula-
tion, the NIH scientists first confirmed a num-
ber of earlier studies that had been performed
on exteriorized sheep fetuses (deteriorating for
lack of a physiologically stable support system).
These earlier studies had shown that very little
blood flows through the lungs during fetal life,
but that most of the blood traveling toward the
lungs is instead diverted back into the general
body circulation by a blood vessel — the ductus
arteriosus — connecting the pulmonary artery to
the aorta.

The previous studies had also indicated that
constriction and closure of the ductus soon after
birth was triggered by greatly elevated levels of
blood oxygen, and that complete functional closure
required about half an hour.

The currently reported studies provided the
first “non-invasive” proof that higher physiologic
levels of blood oxygen, at constant bloodflow,
close the ductus arteriosus. Moreover, the NIH
experiments revealed that this conversion of the
fetal to an adult form of circulation allowing in-
creased bloodflow through the lungs occurs with-
in 5 minutes of the raising of blood oxygen con-
tent instead of the previously reported half hour.
It is complete by 20 minutes. Furthermore, the
process is reversible — the closed ductus can be
dilated and then closed again by manipulating
blood oxygen tension, even after being closed
for 6 hours. Finally, the scientists observed that
induced respiratory acidosis alone (an increase in
blood acidity — carbonic acid — caused by insuffi-
cient exhalation of carbon dioxide) cannot dilate
the ductus in the absence of a sufficiently high
level of blood oxygen. Metabolic acidosis also
does not delay, disturb or vary this constricting
response.

These findings — heretofore unavailable x-ray
documentation of circulatory phenomena in the
as yet “unborn” fetal lamb — provide additional
evidence for the use of the blood oxygenator to
support newborn human infants during such cri-
ses as respiratory distress syndrome due to hya-
line membrane disease. In such situations, the
oxygenator would not only provide respiratory
support until lung lesions cleared up spontaneous-
ly or in response to medication, but would also
effect closure of the ductus and thus increase

bloodflow through the lungs to actively promote
gas exchange in the lung. (Hyaline membrane
disease kills approximately 25,000 newborn in-
fants each year in the U. S.)

The blood oxygenator may also prove useful
in the management of newborn infants afflicted
with congenital (inborn) heart defects.

Heart Attack Will
Be Studied at UAB

Heart attack kills 500,000-600,000 Americans
per year. New and more sophisticated methods
of treating this killer disease still have not sig-
nificantly altered the appalling death toll from
heart attack when it is accompanied by shock or
congestive failure. In a major clinical research
effort, a system of Myocardial Infarction Re-
search Units has been set up in a small number of
university medical centers by the National Heart
Institute, National Institutes of Health. In these
centers, scientists from many disciplines are fo-
cusing their skills on patients with “heart at-
tacks” which are usually associated with myo-
cardial infarction — the damaging or death of an
area of the heart muscle resulting from a reduc-
tion in the blood supply reaching that area.

The largest and most extensively equipped of
these Myocardial Infaction Research Units is lo-
cated at the Medical Center of the University of
Alabama in Birmingham. This new facility, as a
part of University Hospital, will become opera-
tional next month. The impressive UAB unit,
sponsored by the National Heart Institute and
funded in part by the (Alabama) Vocational
Rehabilitation Service, private philanthropy and
the University of Alabama in Birmingham, is
supported by a prestigious interdisciplinary team
of physicians, surgeons, scientists, computer en-
gineers and technicians. The unit houses a vast
array of instruments and special equipment de-
signed to help diagnose the extent of heart dam-
age, to follow the development of complications
and to improve treatment in ways “hitherto not
possible.”

According to Dr. T. Joseph Reeves, MIRU
Director, the unit is divided into four sections.
The Clinical Section deals directly with patient
care; the Computer Section, staffed by biomathe-
maticians and computer specialists, is concerned
with new applications of computer sciences to
intensive patient monitoring, information retriev-
al and, eventually, direct patient care; the Pa-

FEBRUARY 1970

97

ORGANIZATION / Continued

thology Section is responsible for study of the
anatomy of blood vessel and heart muscle dis-
eases; and the Bioengineering Section will work
toward the development of different and im-
proved methods of instrumentation to assist the
heart through the critical period when life and
death hang in the balance.

Dr. Reeves explained that physicians in the
unit are interested in identifying heart abnor-
malities more quickly than has been possible in
the past. Many deaths, he pointed out, occur
before the victim ever reaches the hospital; a
great many more occur suddenly, even after ad-
mission. If symptoms and complications are read-
ily identified, proper treatment can be started
immediately.

Members of the MIRU staff also are particu-
larly concerned with the problem of the compli-
cated myocardial infarction. Recent advances in
electrocardiographic monitoring have greatly re-
duced the hazard of death from electrical insta-
bility of the heart which, if not promptly treated,
may lead to total disorganization of the heart
beat. However, relatively little progress has been
achieved in the treatment of those patients in
whom a major injury to the heart muscle pre-
vents the heart from functioning adequately as a
pump. When this occurs, “congestive heart fail-
ure” or cardiogenic shock develops. Under these
circumstances, even in the most modern clinical
coronary care units, the mortality rate remains
extremely high. One of the major objectives of the
new unit is to materially reduce death from this
cause.

One of the major facets of the MIRU program
at the UAB is the use of circulatory assist de-
vices. Ready for application to patients is the
Bramson Membrane Lung (artificial heart-lung
machine). The physician-scientists in the new
unit believe that if the severely damaged heart
can “rest” for a number of hours it will have a
better chance of recovering its strength. During
this time, the membrane oxygenator will supply
the vital organs of the body with the required
blood. A special room of the unit is designed for
this circulatory assist program.

In dealing with heart attack victims, physicians
have been meeting crises as they occur and, as a
result, data accumulation has suffered. An impor-
tant aspect of the program will be data accumu-
lation through use of a uniquely programmed
IBM 1800 computer which simultaneously mon-

itors and records all important bodily functions
of patients in the four MIRU beds. The com-
pany-programmed system has been altered by a
support group of highly skilled specialists so that
it will perform numerous functions never before
programmed for conventional computer opera-
tions. The MIRU computer team edited and ex-
panded the master programming system to “cus-
tom-fit” the job. One improvement is the reten-
tion of certain basic program modules needed for
a number of “tasks.” This retention capability
eliminates the need for external information stor-
age and time consuming re-entry of instructions
which are needed on a continuing basis.

The University’s computer authority, Dr. Jo-
siah Macy, Jr., said that this system gives re-
searchers the computer flexibility they need with-
out sacrificing high performance in simultaneous
data-collection and monitoring of patients.

“In addition to standard monitoring proce-
dures, information retention and staff-alerting
functions, we hope to use the computer for pa-
tient care procedures as soon as feasible,” Dr.
Macy said. Some similar patient care functions
are already in everyday use at the UAB Univer-
sity Hospital for postoperative open heart surgery
patients.

Other equipment will permit x-ray and fluoro-
scopic examination of the heart without moving
the patient. Specially built beds swing smoothly
into the required position, leaving behind the
image-distorting portion of the bed frame.

The program also will include new instrumen-
tation for cardiovascular diagnosis of critically
ill patients. Included are such devices as radar
and sonar probes, which are used to measure
heart size and cardiac chamber motion, as well
as the conventional electrocardiogram, phono-
cardiogram and other more routine procedures.

Central Medical
Elects New Officers

Central Medical Society’s new slate of officers
recently took office. President for 1970 is Dr.
William O. Barnett of Jackson. Dr. T. E. Wilson
III is the new vice president and Dr. William
Pontius is president elect.

Dr. Robert P. Henderson was elected secretary
of the society. Outgoing president is Dr. Frank
Bower.

98

JOURNAL MSM A

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Index to Advertisers

AMPAC, MPAC 95

Arch Laboratories 99

Breon Laboratories 14A, 14B, 14C, 14D

Burroughs-Wellcome 80A

Campbell Soup Company 68A

Geigy SOB, 80C

Highland Hospital 15

Hillcrest Hospital 10

Hoechst Pharmaceuticals 17

Hynson, Westcott and Dunning 3

Kay Surgical 99

Lakeland Nursing Center 7

Lederle Laboratories 4, 12, 14, 87

Eli Lilly and Company front cover, 18

National Drug Company second cover, 84A, 84B

Parke Davis and Company 92C, 92D

Pharmaceutical Manufacturers Association 16

Wm. P. Poythress 92A

A. H. Robins Company 10A, 10B, 11, 68D, 83, 92B
Roche Laboratories 6, 89, fourth cover

Sando/. SOD

G. D. Searle 68B, 68C

Smith. Kline and French 8

Thomas Yates and Company third cover

FEBRUARY 1970

99

Department of Health, Education, and Welfare , a bureaucrat* s
bureaucracy, may be broken up by Nixon administration. Word is
that Secretary Finch is finding it impossible to manage sprawl-
ing agency with 107,000 employees, 255 separate programs, and an
annual budget of $60 billion. AMA has long advocated a separate
cabinet level Department of Health and may get it yet.

American Hospital Association forecasts a stronger and bigger role
for hospitals in delivery of medical care in the 1970 *s. AHA says
that the "hospital administrator must increasingly assume the role
of chief executive officer," recognizing that he has a community
responsibility. Prediction also says that physicians will be
"assaulted with greater demands to pay attention to the social and
economic problems of medical care."

Los Angeles veterinarians have organized a program of small animal
care for pets of welfare recipients, calling it Vet-aid. Idea is
that 610,000 Angelinos on welfare can*t afford vet fees and pets
suffer as a result. Animal Health Foundation of California will
administer program which is starting up with $200,000 obtained from
public contributions.

Brandeis University reports in a nationwide study of child abuse
that 90 per cent of incidents occur in the child* s home. Mothers
abuse children more frequently than fathers, and most incidents
involved beatings. Half the children and two- thirds of the abusive
parents showed deviation in behavioral characteristics. Only 17 pe
cent of child abusers were convicted by courts.

Louisiana State University will construct a $10.6 million school
of veterinary medicine on the Baton Rouge campus on a 44 acre site
in the shadow of Tiger Stadium. Federal funds will be provided by
HEW grant under Health Manpower Act. Construction is scheduled to
begin next June and school is to be opened in 1973. At present,
only school of veterinary medicine in Alabama— Louisiana— Mississippi
area is at Auburn University.

/olume XI
Number 3
March 1970

• EDITOR

William M. Dabney, M.D.

. ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

MANAGING EDITOR
Rowland B. Kennedy

EDITORIAL CONSULTANT
Betty M. Sadler

EDITORIAL ASSISTANT
Nola Gibson

PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.
Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

THE ASSOCIATION
James L. Royals, M.D.

President

Paul B. Brumby, M.D.

President-elect
Walter H. Simmons, M.D.

Secretary-Treasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell

Executive Assistant

fhe Journal of the Mississippi State
Medical Association is owned and pub-
ished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
icutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
>f publication, 1201-5 Bluff Street, Fulton.
Missouri 65251. Subscription rate, $7.50
>er annum; $1 per copy, as available. Ad-
rertising rates furnished on request,
iecond-class postage paid at the post office
it Fulton, Missouri.

CONTENTS

original papers

Emergency Surgery for
Acute Myocardial

Infarction 101 Hilary H. Timmis, M.D. ;

David Davis, M.D.;
Patrick H. Lehan, M.D.;
and James D. Hardy, M.D.

Idiopathic Hypertrophic

Subaortic Stenosis 106 Karl W. Hatten, M.D.

SPECIAL ARTICLES

Changing Methods and

Changeless Principles 1 10 William K. Keller, M.D.

Radiologic Seminar
XCIII: Inferior

Vena Cavography 1 14 Ottis G. Ball, M.D.

EDITORIALS

Invasion of Privacy:

New Angle on Smoking

A Punitive Bill Aimed
at Physicians

Restraining Devices Help
Mother Make Sure

The Inside Story on
AMA Membership

The Old Admonition:
Watch Those Narcotics

117 ASH and CRASH

1 1 8 Malpractice Threat

1 1 9 Keep the Tykes Alive

119 Facts Explain Figures

120 Do's and Don'ts

THIS MONTH

The President Speaking 1 16 ‘Or Lose by Default'
Medical Organization 129 102nd Annual Session

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR MARCH 1970

D. C. Medical Society
Discourages Smoking

The Medical Society of the District of Colum-
bia, in mid-January, launched a new offensive
against smoking. It called for a ban on smoking
in public schools, an end to cigarette sales in hos-
pitals, and for separate hospital facilities for pa-
tients sensitive to cigarette smoke.

The Society also asked that physicians place
“No Smoking” signs in their offices, that the gov-
ernment stop using tax dollars to promote the
U. S. tobacco industry, and that the Federal
Aviation Administration and Congress approve
petitions and bills for either separate smoking
compartments or smoking bans aboard commer-
cial airliners.

Joining the Society were 60 public and private
organizations comprising the D. C. Interagency
Council on Smoking. In addition to all-out edu-
cational promotions, physicians and ministers
staffed four five-day withdrawal clinics, sponsored
by the Seventh-Day Adventist Church.

Voluntary Health
Conference Slated

The third national voluntary Health Confer-
ence will be held at the Statler-Hilton Hotel in
Washington, D. C., May 7-8, 1970. Sponsored by
the AMA’s Board of Trustees and Council on
Voluntary Health Agencies, the meeting will em-
phasize “Health Team Relationships: Profession-
al Associations, Governmental Agencies, Volun-
tary Organizations.”

National leaders will explore the roles, respon-
sibilities and relationships among professional as-
sociations, governmental agencies and voluntary
organizations in the provision of health care,
broadly interpreted to include research, health
education and health services.

Information on registration and reservations
may be obtained from Dr. D. A. Dukelow, Con-
ference Coordinator, Department of Health Edu-
cation, AMA, 535 North Dearborn Street, Chi-
cago, 111. 60610.

cFkM? (Vs t

HOSPITAL

(Formerly Hill Crest Sanitarium)

7 000 5TH AVENUE SOUTH
Box 2896, Wood lawn Station
Birmingham, Alabama 35212
Phone: 205-836-7201

A patient centered
independent hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 44 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James A. Becton, M.D.„ F.A.P.A.

CLINICAL DIRECTORS:

James K. Ward, M.D., F.A.P.A.
Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL;

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

SWt® C/test

HOSPITAL

BIRMINGHAM, ALABAMA

March 1970

or Doctor t

;sh an estimated six weeks to go, the Regular Session of the Legis-
“sure is considering antimedicine and anti-M.D. bills. Biggest
”iger to public health is Senate Bill 1905, proposal to license
propraetors and to put badge of legality and respectability on
,iLt. Bill is sponsored by Sens. Robertson, Yancy, Perdue, and
kson and has been referred to Senate Public Health Committee.

In the House. HB 407 would make a shambles of judicial
safeguards in medical malpractice cases. Bill would
permit jury awards without corroborative medical testi-
mony, sending premiums for professional liability in-
surance sky high or drive it from state market.

.;fant mortality showed a decrease in Mississippi during third quar-
rr of 1969 over same three months a year previously. State Board
v Health reports infant deaths down to 337 from 39^, a decrease of
.. per cent. In the same period, live birth rate went up 5.4 per
Mt, up 6.8 per cent for whites and 4 per cent for nonwhites.

liy news media sources are saying that it's no longer a question of
r f , only "when and what , ,l on national compulsory health Insurance .
rans are in offing from Reuther, Javitts, Rockefeller, and Kennedy.
l A.* s Medicredit is voluntary, however. But Nixon administration
t pears to oppose all, saying that nation does not have health man-
iwer to staff program and that Mwe can't even handle Medicaid.”

igrican College of Surgeons has outlined policy for procedures in-
^lving human experimentation. Physicians and institutions must be
lalified, procedures explained, potential benefits must outweigh
sks, and surveillance guaranteed. College Regents also prescribed
irefully controlled public release of clinical results with appro-
bate restraints.

yen of nine multi-county regions in Mississippi now have mental
alth centers or are preparing to go operational soonl Centers
ready open include Tupelo, first in state, and Oxford. Units for
.ckson and Greenville are under construction, and plans are ad-
nced in Meridian, Clarksdale, and Gulfport. Program is largely
derally funded with grants totaling $3.7 million.

Rowland B. Kennedy
Executive Secretary

THE JOURNAL FOR MARCH 1970

1 0

IRS Requires
Identification Number

The Internal Revenue Service has ruled that
Section 604 (a) of the Internal Revenue Code re-
quires all insurance carriers to file form 1099
with respect to medical expense benefit payment
in excess of $600 in any year made under Group
Health Insurance policies directly (that is as-
signed to the physician).

The information necessary for the various car-
riers of group health insurance to make their re-
port to IRS requires that they know the Tax-
payer Identification Number of the physician
(Social Security Number of the individual physi-
cian or Employer Identification Number as ap-
propriate).

Beginning January 1, 1970, the carriers can-
not issue a draft directly to a physician unless it
has the appropriate Taxpayer Identification Num-
ber. All physicians should inform their billing
clerks to include the appropriate information on
any claim forms where an assignment is involved
to prevent delay in processing the claim.

AMA Hosts Meet
of Medical Executives

The AMA hosted a unique meeting in Chicago
Jan. 28-29 to strengthen communications and li-
aison between its components and related pro-
fessional organizations. Invited to the Confer-
ence for Senior Medical Executives were 249 ex-
ecutives of state and county medical associations
and of 32 medical specialty societies.

The two-day session was designed to encour-
age the free exchange of information between
the AMA administrative staff and the registrants
on medical programs and problems, and to pro-
mote a greater utilization of AMA services.

Each of the AMA division directors presented
a summary of activities performed by his staff,
and additional reports were made by members
of the Office of the Executive Vice President.

Dr. Ernest B. Howard, AMA executive vice
president, opened the Conference. After the in-
dividual presentations, the registrants participat-
ed in eight different discussion groups which fo- \
cused on specific programs, services, and needs
in which both the AMA and the invited organi-
zations can participate to their mutual benefit.

—The lowest priced tetracycline— nystatin combination available—

bract Surgeon Washington - Taking a cue from the way things

doming Back were done a century ago, the Gates Commission,

studying health needs of the military and their
sndents, has recommended that civilian physicians be employed to
re domestic military installations, thereby easing off Doctor
ft. Commission also recommends expanding CHAMPUS to cover all
Lth services for active duty dependents and retirees.

Lth Insurance, New York - Private health insurance and prepay-

33 Grow in * 69 ment plans grew to record highs in 1969, accord-

ing to the Health Insurance Institute, More than
out of 204 million Americans own some form of health care cover-
, Companies and plans paid out $13.5 billion last year with $8
Lion going to hospitals, $4 billion to physicians and other prac-
Loners, and remainder for miscellaneous benefits.

Dility Hike Montgomery - The Medical Society of the State of

i in Alabama Alabama says that their members will pay up to

$1,000 each for professional liability insurance
srage in 1970. State has 37 suits now pending totaling $7.9 mil-
l in plaintiffs* claims. Rate increase amounts to 25 per cent for
sral practitioners up to 75 per cent for anesthesiologists , sur-
is, and those in ob-gyn. Upward trend is national in scope.

May Warn Pill Washington - In an unprecedented move, PDA may
Lents Directly send warnings on oral contraceptives directly to

women rather than through usual channel of M,D. *s.
1 is that message would be simple, direct, and nontechnical. But
broversy is likely to break out if a federal agency invades time
)red physician-patient relationship. Some see move as undermining
Lent confidence in physicians. Before such action could be taken
putting messages in packages, PDA must publish intentions.

Seeks Bigger Chicago - American Medical Association says that
Lth Care Plans 0E0 will try to expand poverty health care pro-
grams by direct aid to hospital outpatient de-
bments. Idea is to intensify care in ghetto. Pattern under Re-
Licans is same as when LBJ was in: Although the Congress has cut

general budget for three successive years, agency's health care
jram has always been expanded.

■%. 1

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

March 1970, Vol. XI, No. 3

Emergency Surgery
For Acute Myocardial Infarction

HILARY H. TIMMIS, M.D.; DAVID DAVIS, M.D.;
PATRICK H. LEHAN, M.D.; and JAMES D. HARDY, M.D.

Jackson, Mississippi

The role of surgery in the palliation of coro-
nary atherosclerosis is an accepted clinical mo-
dality, and the recent literature documents the
usefulness of many operative procedures.1’ 2> 3> 4
Initially, the challenge of atherosclerotic myo-
cardiopathy was met by surgical techniques not
requiring cardiopulmonary bypass to repair le-
sions such as ventricular aneurysm. Open heart
surgery is now commonly used for the correction
of this and other sequelae of myocardial infarc-
tion. Furthermore, operative procedures aimed at
preventing myocardial infarction and relieving
symptomatic myocardial ischemia are also per-
formed in many centers. These operations con-
sist of indirect methods to increase myocardial
blood flow, mainly by internal mammary artery
implantation and, less frequently, direct repair of
locally occluded coronary vessels by endarterecto-
my and grafting techniques. Generalized coro-
nary atherosclerosis resulting in progressive cardi-
ac dysfunction and imminent death, has been
managed successfully by cardiac replacement and
is the most common indication for heart trans-
plantation.

From the Departments of Surgery and Medicine, Uni-
versity of Mississippi Medical Center.

Until recently, the surgical armamentarium
had nothing to offer the patient in cardiogenic
shock due to myocardial infarction and the fail-
ure of medical measures invariably resulted in

Until recently, the surgical armamentari-
um had nothing to offer the patient in car-
diogenic shock due to myocardial infarction,
and the failure of medical measures invari-
ably resulted in death. Two years ago
Mobin-Uddin and Heimbecker independent-
ly reported results of a radical surgical con-
cept used in these cases. In this paper the
authors report the case of a middle-aged
male who underwent surgery following pe-
ripheral vascular collapse from acute rup-
ture of the ventricular septum after myo-
cardial infarction.

death. However, in 1947, Murray reported a sig-
nificant improvement of survival rate in dogs af-
ter acute occlusion of the anterior descending
coronary artery when the infarcted muscle was

MARCH 1970

101

EMERGENCY SURGERY / Timmis et al

immediately excised."’ Twenty years later, this
radical surgical concept was corroborated inde-
pendently by Mobin-Uddin and Heimbecker, and
the latter further described the successful clinical
application of the procedure.6, 7

The following report details our experience
with a middle-aged male who appeared to be a
candidate for this unusual procedure.

CASE REPORT

J.W., a 48-year-old veteran, was transferred to
the University Medical Center for emergency
evaluation and treatment following the sudden
onset of a harsh precordial murmur and periph-
eral vascular collapse while convalescing from a
recent acute coronary occlusion. During cardiac
catheterization, the intravenous administration of
a vasopressor was necessary to maintain an ar-
terial pressure above 90 mm. Hg. His heart was
extremely irritable at this time, and recurrent
episodes of ventricular tachycardia and one of
fibrillation were reversed by direct current shocks.
A left ventricular angiocardiogram revealed a
large left to right shunt at the ventricular level,
and there was very slow clearing of contrast ma-
terial from the left ventricle. It was evident that
cardiac function was critically reduced by the de-
velopment of an intracardiac shunt in addition to
the obvious muscle dysfunction manifested by a
hypokinetic left ventricular muscle. With these
findings, repair of at least the interventricular
septal defect was recognized as the only possible
recourse to survival.

(a)

(b)

Before

After

mm. Fig

mm.Hg

Right atrium

30

10

Pulmonary artery

60/40

25/10

Aorta

50/30

130/80

Figure 7. Intraoperative pressure measurements.

Type specific blood in adequate quantity was
rapidly prepared, and with all in readiness, the
operation was begun. Initially, the right external
iliac artery was exposed under local anesthesia
for arterial input from the heart-lung machine, in
the event of cardiac arrest during anesthetic in-
duction. General anesthesia was then carefully
induced with no untoward change of his vital
signs. The chest was entered through a median
incision and the sternum split in the midline to

expose the entire anterior surface of the heart. On
inspection, the heart appeared grossly enlarged
and both atrial walls were markedly tense due to
biventricular failure. Preparations were rapidly
made to begin cardiopulmonary bypass, particu-
larly since he was requiring increasing levels of
norepinephrine to maintain a pressure above 70
mm. Hg.

When his circulatory load was taken over in
part by the action of the heart-lung machine, the
chamber pressures which were markedly altered
(Figure 1) rapidly returned to normal levels. Af-
ter complete cardiopulmonary bypass was insti-
tuted, the heart was examined more carefully.
Fine adhesions were noted between the antero-
lateral surface of the left ventricle and the parie-
tal pericardium. These were easily lysed, expos-
ing a discolored, inffammed segment of myocar-
dium which moved paradoxically. The right ven-
tricle was then entered through a 5 cm. incision
which avoided major coronary branches. A 2 cm.
ventricular septal defect was noted almost adja-
cent to the apex, behind some heavy trabecula-
tions which were divided. The edges of the defect
were yellow in color, irregular and very thin for a
distance of about 1 cm. The decision was made
at this point to repair both the damaged left ven-
tricle as well as the ventricular septum, to give
him the best possible chance for survival. The
non-contractile segment of the left ventricle was
excised, leaving a circular defect about 5 cm. in
diameter, the cut edges of which were mottled
and ecchymotic (Figure 2).

REPAIR COMPLETION

Repair was accomplished with deep, interrupt-
ed mattress sutures of Dacron backed with Teflon
felt to prevent their tearing through the soft myo-
cardium (Figure 3). The septal defect was closed,
in turn, with a large Teflon felt patch which was
anchored with mattress sutures of Dacron backed
on both sides of the septum with Teflon pledgets
(Figure 4). At the completion of the repair,
no arterial blood was noted in the right ven-
tricle. The right ventriculotomy was then closed
and air evacuated from the heart after which car-
diopulmonary bypass was gradually discontinued.
The heart accepted the circulatory load remark-
ably well and continued to contract vigorously
when all support was discontinued. Chamber
pressures were measured again and are shown in
Figure 1. Pulmonary artery and right atrial sam-
ples were collected for oxygen analysis and
were found to be equal, indicating complete re-
pair of the intracardiac shunt.

Reaction from anesthesia was uneventful and

102

JOURNAL MSMA

Figure 2. Following exploration of the ventricular
septum through a right ventriculotomy, a 5 cm. seg-
ment of akinetic, discolored left ventricular myo-
cardium was excised from the apex.

/

/

Figure 3. The left ventricular defect was closed
with Dacron mattress sutures backed with Teflon
felt strips.

during the first 24 hours, assisted ventilation was
used to give maximal oxygenation. He initially
exhibited a low cardiac output picture charac-
terized by peripheral vasoconstriction and oli-
guria, although his arterial pressure remained at
a satisfactory level. However, he responded well
to the temporary additional support supplied by
an infusion of isoproterenol and throughout the
remainder of his initial hospitalization, exhibited
no further evidence of reduced cardiac function.
On the second postoperative day, ventricular ir-
ritability became evident by the appearance of
frequent premature ventricular contractions and
episodes of ventricular tachycardia. Isoproterenol
was discontinued, digitalis was withheld and a
continuous infusion of xylocaine hydrochloride
was begun.

Potassium supplements were also given to keep
the serum potassium above 5.0 mEq/1. Despite
a progressive increase of xylocaine administra-
tion to a maximum level of 4 mg min, intermit-
tent ventricular arrhythmias persisted. For the
most part, satisfactory cardiac output was main-
tained during these periods; however, on occa-
sion, direct current shock was necessary to ob-
tain a more suitable rate and arterial pressure.
Increments of procaine amide, 250 mg., were
added to his program along with Dilantin, which

was used primarily for mild convulsive activity.
On the eighth postoperative day, evidence of ven-
tricular irritability began to recede and his myo-
cardial depressants were gradually reduced and
finally stopped.

VASCULAR CATASTROPHE

By the 15th postoperative day, he was ambula-
tory and his wounds were healing in an uncom-
plicated manner. At this time, he was transferred
to his referring hospital for continued convales-
cence and care. Two days later, following the on-
set of severe chest pain and diaphoresis, arterial
pressure fell from 160 to 80 mm. Hg. and he be-
came severely oliguric. A vascular catastrophe
was suspected, particularly pulmonary emboliza-
tion or recurrent mvocardial infarction, and most
of the evidence pointed to the latter. He was
moved immediately to the intensive care area of
the University Medical Center where ventilatory
and circulatory support were continued.

Since cardiac output was inadequate for satis-
factory cerebral and renal perfusion, he became
severely obtunded and his blood urea nitrogen
began to rise rapidly. Cardiac action was im-
proved somewhat by isoproterenol infusion and
further augmented with intravenous Glucagon.
Peritoneal dialysis was instituted to remove ex-

MARCH 1970

103

EMERGENCY SURGERY / Timmis et al

cess body water and to improve the ionic en-
vironment of his heart. He began to improve
steadily with these adjuncts which were then
gradually withdrawn and finally discontinued on
the ninth hospital day. The remainder of his con-
valescence was uneventful and he gained strength
steadily. Long-term anticoagulation was institut-
ed because of his history of recurrent myocardial
infarction as well as for the treatment of lower
extremity thrombophlebitis. At the time of his
hospital discharge, he was taking Coumadin, digi-
talis, and a low cholesterol diet.

Prosthetic valve replacement for mitral regur-
gitation following papillary muscle infarction,
ventricular aneurysmectomy, and cardiac re-
placement have all been performed at the Uni-
versity Medical Center for acute and chronic se-
quelae of coronary atherosclerosis. In most in-

stances, a methodical evaluation by cardiac cath-
eterization and angiocardiography is absolutely
essential to define the specific mechanical abnor-
mality, the magnitude of residual myocardial re-
serve and the status of the coronary arterial tree.

DISCUSSION

When peripheral vascular collapse intervenes,
as in this patient, the primary aim of study is to
pinpoint the intracardiac abnormality so that the
feasibility of effective emergency surgery can be
determined. A large left to right shunt was dem-
onstrated here, which could be repaired in a rel-
atively straight forward manner. However, in ret-
rospect, we believe that survival depended to a
greater extent on excision of necrotic myocar-
dium, which not only failed to contribute to over-
all left ventricular function, but actually critical-
ly reduced it. This information was provided by
an angiocardiogram, which demonstrated the

Repair of
Right Ventriculotomy

Left Ventricle

Teflon Patch

Teflon Pledgets

Figure 4. The ventricular septal defect was re-
paired with an over-size patch anchored with mattress
sutures of Dacron backed on both sides of the septum
with Teflon pledgets. Since there was no anterior

rim, the sutures in this area were passed through the
anterior wall of the right ventricular apex and tied
down over Teflon felt. The right ventriculotomy was
then closed.

104

JOURNAL MSMA

akinetic left ventricular segment as well as very
delayed emptying of this chamber.

Preliminary exposure of the iliac artery for ar-
terial input from the pump is used in instances
where limited cardiac reserve or cardiac irrita-
bility are a major impediment to safe anesthetic
induction. Since arterial pressure began to decline
further from the moment the chest was opened
until partial support was given by the heart-lung
machine, it was distinctly advantageous to have
this period as short as possible.

Identification of the extent of myocardial in-
farction was based mainly on an evaluation of
myocardial contractility rather than on the ap-
pearance of the epicardial surface. In order to re-
sect the damaged muscle, it was necessary to
transect some major diagonal tributaries. How-
ever, the coronary arterial branches did not bleed
and all aspects of the cut edge of the left ven-
tricular opening exhibited ecchymoses.

Repair of both the left and right ventricu-
lotomies was greatly facilitated by the use of
mattress sutures backed with cloth (Teflon felt).
This maneuver is helpful for reliable approxima-
tion of all friable tissues with or without inflam-
matory edema. Repair of the septal defect posed
a special problem in that the edges were necrotic,
and no tissue was present where the septum nor-
mally is continuous with the apical myocardium.
Consequently, about half of the mattress sutures
anchoring the septal patch were passed through
the apex and tied over Teflon pledgets.

Following cessation of cardiopulmonary bypass
for the repair of any cardiac abnormality, the
manner in which the heart resumes the circula-
tory load is usually a reliable yardstick of both
early and long-term cardiac function. In this in-
stance, restoration of cardiac function was re-
markably good immediately and proved to be
sufficient to carry the patient through innumer-
able episodes of tachyarrhythmias as well as an-
other bout of peripheral vascular collapse, prob-
ably due to recurrent myocardial infarction.

Intravenous isoproterenol was administered at
two points in his hospital course to provide the
improvement of cardiac contractility and output
which were essential for ultimate recovery. In
most areas, this drug has replaced the routine in-
fusion of norepinephrine to produce a strong
ionotropic effect without undesirable stimulation
of alpha receptors, notably extensive vasocon-
striction. Tachycardia is seldom severe and the
reduction of peripheral vascular resistance en-
hances cardiac output further. Another extra-
ordinary feature of this case consisted of the de-
gree of pharmacologic depression which was nec-
essary to suppress irritable ventricular foci.

Xylccaine was chosen because of its titratability
and relative lack of toxicity. In our experience it
is seldom necessary to use more than 2 mg/min
for postoperative ventricular arrhythmias and
usually half this dose suffices. This patient con-
tinued to exhibit signs of irritability with 4 mg/
min at which level mild convulsive activity due to
xylocaine appeared. Here the myocardial de-
pressant effect of Dilantin may have supplied the
additional suppression which was necessary for a
safe recovery.

Needless to say, persistent first hand observa-
tion and care by a trained and devoted resident
and nursing staff was essential to initiate and
monitor the various therapeutic measures which
underwrote his survival.

SUMMARY

A middle-aged male in peripheral vascular
collapse from acute rupture of the ventricular
septum following myocardial infarction under-
went emergency cardiac catheterization and open
heart surgery. In addition to correction of a ven-
tricular septal defect, infarcted left ventricular
myocardium was excised and the ventricle re-
paired. Restoration of left ventricular function
was gratifying, although his postoperative course
was complicated by ventricular irritability and re-
current infarction. He subsequently recovered
and was discharged. Some aspects of the opera-
tive procedure and postoperative management
are reviewed. ***

2500 North State St. (39216)
Aided by U.S.P.H.S. Grant No. HE-06163.

REFERENCES

1. Rossi, N. P.; Flege, J. B.; and Ehrenhaft, J. L.: Sur-
gically Treatable Complications of Myocardial In-
farction, Surgery 65:118, 1969.

2. Favaloro, R. G.; Effler, D. B.; Groves, L. K.; West-
cott, R. N.; Suarez, E.; and Lozada, J.: Ventricular
Aneurysm — Clinical Experience. Ann. Thor. Surg.
6:227, 1968.

3. Spencer, F. C.; Reppert, E. H.; and Stertzer, S. H.:
Surgical Treatment of Mitral Insufficiency Secondary
to Coronary Artery Disease, A.M.A. Arch. Surg. 95:
853, 1967.

4. Sheldon, W. C.; Sones, F. M.; Shirey, E. K.; Fergus-
son, D. I. G.; Favaloro, R.; and Effler, D. B.: Re-
constructive Coronary Artery Surgery: Postoperative
Assessment, Circulation 39:1-61, 1969.

5. Murray, G. : The Pathophysiology of the Cause of
Death from Coronary Thrombosis, Ann. Surg. 126:
523, 1947.

6. Mobin-Uddin, K. : Surgical Treatment of Myocardial
Infarction. Presented at 16th Annual Session of The
American College of Cardiology, Washington, D. C.,
Feb. 17, 1967.

7. Heimbecker, R. O.; Chen, C.; Hamilton, N.; and
Murray, D. W. G. : Surgery for Massive Myocardial
Infarction, An Experimental Study of Emergency In-
farctectomy, Surgery 61:51, 1967.

MARCH 1970

105

Idiopathic Hypertrophic

Subaortic Stenosis

KARL W. HATTEN, M.D.
Vicksburg, Mississippi

The concept of obstruction of the aortic out-
flow tract has developed rapidly since the defini-
tive report by Brock1 in 1957. Other cases had
been reported prior to 1957; however. Brock ini-
tiated the concept of dynamic obstruction. Pre-
viously, patients with idiopathic hypertrophic sub-
aortic stenosis were diagnosed as having either
valvular heart disease or coronary atherosclerosis
depending on which symptoms and physical find-
ings were most prominent. The delay in describ-
ing IHSS was in part due to the paucity of ana-
tomical findings at surgery or at postmortem. The
present case concerns a patient whose initial di-
agnosis was valvular heart disease and who later
developed symptoms of arteriosclerotic heart dis-
ease.

This 40-year-old white man was first noted to
have a heart murmur at the Naval Academy in
1950. He was not allowed to finish his training
there but was given a commission in the Con-
struction Battalion and finished his service time
without difficulty. At the time of discharge he was
told the murmur was still present. In 1965 be-
cause of the increase in intensity of the murmur,
the patient underwent cardiac catheterization at
the University Hospital in Jackson. At this time a
cineangiogram of the left ventricle was done and
did not show mitral regurgitation. On measuring
the pressures no gradient was noted between the
left ventricle and the subaortic area. However, it
is noted that the pressures were somewhat erratic
and could not be explained at that time. There
was no evidence of septal defects.

Read before the General Session on Medicine, 101st

Annual Session, Mississippi State Medical Association,

Biloxi, May 14, 1969.

Following this the patient had a rather insidi-
ous onset of shortness of breath on exertion and
then began to develop chest pain. These pains
were over the precordial area and usually came

Prior to 1957, patients with idiopathic
hypertrophic subaortic stenosis were diag-
nosed as having either valvular heart disease
or coronary atherosclerosis. A case is pre-
sented of a patient with IHSS whose initial
diagnosis was valvular heart disease and who
later developed symptoms of arteriosclerotic
heart disease. The author discusses diagnosis
and treatment of the syndrome.

on after exertion, especially if he had just eaten.
The pains would last some two to three minutes,
would be dull, aching in nature, but would not
radiate into his arm or neck. They also seemed
to occur more frequently in the afternoon or
when he was fatigued.

Blood pressure in the left arm was 110/75.
The pulse was brisk and full. The neck veins
were flat. Examination of the heart revealed that
the PMI was 1 cm. lateral to the mid-clavicular
line in the 5th intercostal space. A thrill was not
present. There was no evidence of a double
apical impulse. Auscultation revealed a grade
four over six, harsh, diamond-shaped, systolic
murmur. It was heard best along the left sternal
border but did radiate into the aortic and pul-
monic areas. It did not radiate into the axilla,
neck, or into the subscapular areas.

106

JOURNAL MSMA

In May 1967, because of the chest pain, the
patient had an electrocardiogram and double
Master’s two-step test performed, and the double
Master’s two-step test was interpreted as being
positive. He was begun on isosorbide dinitrate
(Isordil) and nitroglycerin. On these medications
the patient noticed no improvement in the symp-
toms. In October 1968, the patient was seen at
the Veterans Administration Hospital. It was rec-
ommended that he have a repeat of the cardiac
catheterization. This was performed at the Uni-
versity Medical Center. At that time the cardiac
catheterization revealed that there was a 60 mm.
mercury gradient between the left ventricle and
its outflow tract. The cineangiographic studies
showed mitral regurgitation and an area of nar-
rowing in the left ventricular outflow tract. With
these findings it was the impression that the pa-
tient had idiopathic hypertrophic muscular sub-
aortic stenosis.

He was treated with propranolol in increasing
dosages. His exercise tolerance improved, and
there was a decrease in the number of episodes
of chest pain. The propranolol dosage was in-
creased to 30 mg. four times a day. However, on
this dosage his heart rate slowed to 45 at rest.
He felt somewhat uncomfortable and had a
vague feeling of shortness of breath. The dosage
was reduced and his heart rate increased to 60 to
65 per minute and the symptoms disappeared.

IHSS STATISTICS

Idiopathic hypertrophic subaortic stenosis has
been reported in the newborn and the elderly.
The murmur is discovered in the asymptomatic
patient at the average age of 15 years. The av-
erage age of onset of symptoms, using the New
York Heart Association Classification, is 27 years
for functional class II and 35 years for combined
classes III-IV. In nearly all studies there is a pre-
dominance of males.2

The most common presenting symptoms are
dyspnea, angina pectoris, lightheadedness, and
syncope. Palpitations on assuming the recumbent
position is a worrisome symptom for some pa-
tients.3 Several genealogies of familial muscular
subaortic stenosis have been compiled.4’ 5 In
these families an unusual number of sudden un-
explained deaths have occurred in seemingly
healthy young people. The mode of inheritance is
thought to be Mendelian dominant.

The physical examination reveals no distinc-
tive features such as seen in supravalvular aortic
stenosis.6 Patients with hypertension and outflow
obstruction are thought to represent a different
disease complex and are excluded from the IHSS

group. The pulse in IHSS rises rapidly in early
systole but is not as bounding as in aortic in-
sufficiency. The apex of the heart is frequently
lateral to the mid-clavicular line. In addition to
the ventricular impulse a palpable atrial gallop
may be present and is called a double apical im-
pulse. Forty-two per cent of the patients in one
study had an apical systolic thrill. A systolic ejec-
tion type of murmur in the second and third left
intercostal spaces is the most consistent finding.
This murmur rarely radiates into the aortic or
neck region with any degree of intensity. A dia-
stolic murmur may be present but is infrequent
and a distinct systolic ejection click is not found
in IHSS.

CARDIOMEGALY SEEN

Radiological and electrocardiographic studies
reported in the literature show that in 70 per cent
of the patients, routine chest roentgenograms re-
vealed cardiomegaly. The electrocardiogram of
patients with IHSS exhibited a sinus rhythm and
atrial fibrillation was rare. Abnormal P waves
were present in 50 per cent of the patients with
sinus rhythm. Although a few cases of Wolff-
Parkinson-White syndrome have been reported,
most patients had normal P-R intervals.2 Left bun-
dle block frequently occurs after surgery, but in
the preoperative state the QRS duration is usually
normal." Braunwald2 found Q wave abnormali-
ties in 56 per cent of 123 patients. Some observ-
ers believe that the hypertrophied septum is the
reason for this change and have attempted to lo-
calize the area of greatest enlargement by this
electrocardiographic pattern. As would be ex-
pected, 70 per cent of the patients in this same
study had electrocardiographic findings of left
ventricular hypertrophy.

CHARACTERISTIC PATTERNS

Although some of the cases of IHSS have ele-
vated pulmonary artery pressures, the most spe-
cific finding is the gradient between the left ven-
tricle and the subaortic area. The catheter-with-
drawal tracings in IHSS have a characteristic
pattern. As the recording point passes distal to
the muscular obstruction in the ventricle the dia-
stolic pressure remains fixed, but the systolic pres-
sure decreases. On withdrawing the catheter into
the aorta, the systolic pressure remains constant,
and the diastolic pressure becomes elevated.28 Iso-
proterenol has been used to demonstrate a ven-
tricular gradient in suspected cases that could not
be proven in the conventional manner.9 It was al-
so found that methosamine, a sympathomimetic

MARCH 1970

107

SUBAORTIC STENOSIS / Hatten

amine, given intravenously, abolished the ven-
tricular gradient. The arterial pressure pulse in
muscular subaortic stenosis has a characteristic
configuration. The peak arterial pressure is
reached in less than one-tenth of a second from
the beginning of isotonic contraction and falls
sharply in mid-systole just as the left ventricle is
reaching its peak pressure, only to rise to a sec-
ond peak as the left ventricle prolongs its con-
traction.8 The first peak in the tracing is called a
“percussion” wave, and the second wave is re-
ferred to as the “tidal” wave.10

Criley has observed several patients in whom a
significant left ventricular gradient was present,
but in whom, outflow tract obstruction was not
seen by left ventricular cineangiocardiography.
The cardiac muscle in these patients is abnormal-
ly thick and the left ventricle empties more rap-
idly than normal; therefore, a “hypertrophic hy-
perkinetic cardiomyopathy” is present.11 To com-
plicate matters even further, the gradient can
vary from day to day and even be affected by
body position. Braunwald demonstrated an in-
crease in the subaortic gradient by tilting the pa-
tient head up, 45 degrees. The gradient was re-
duced by lowering the patient, head down, 20
degrees, or elevating the legs.13

VENTRICULAR GRADIENT

Angiocardiograms alone cannot be used to
make the diagnosis of IHSS without previous
knowledge of the presence of a ventricular gradi-
ent. The thickened left wall of the ventricle en-
croaches upon the inferior portion of the outflow
tract, giving it the shape of a cone with its base at
the aortic valve. The cone is sharp in appearance
during systole and truncated during diastole. The
cavity of the left ventricle has been observed to
be narrowed by the increased muscle mass but
there is little or no longitudinal contraction.12

Successful surgical treatment of IHSS has been
reported by closed transventricular instrumental
dilatation, open simple ventriculomyotomy,14 and
excision of obstructing muscle mass through the
left atrium15 or left ventricle.16 Morrow reported
10 cases treated surgically with one postoperative
death.17 In six patients a ventricular gradient was
absent at rest and on exercise, but the gradient
could be demonstrated by infusion of isoprotere-
nol. Surgical complications which have been en-
countered are as follows: left bundle-branch
block, heart failure, sudden death, mitral insuf-
ficiency, uncontrollable bleeding, complete heart

block, aortic incompetence, ventricular fibrilla-
tion, and ventricular aneurysms.18

HEMODYNAMIC DISORDER

The classical medical armamentarium of digi-
talis and nitroglycerin serve only to intensify the
hemodynamic disorder of IHSS. Braunwald10 dem-
onstrated that in patients with IHSS the left ven-
tricular end-diastolic pressure and mean left
atrial pressure rose significantly following ouabain
administration; that cardiac output either fell or
remained unchanged and the systolic pressure
gradient between the left ventricle and the brachi-
al artery rose. Propranolol (Inderal), a Beta-
adrenergic blocking agent has been useful in
treating IHSS. Long-term oral propranolol thera-
py has been of significant symptomatic benefit in
patients with latent and labile outflow obstruc-
tion and is considered the treatment of choice in
these groups. In the more severe forms of IHSS,
propranolol may produce an increase in symp-
toms.20

COMMENT

Since the murmur, in the patient presented,
was known to exist prior to the onset of symp-
toms of angina pectoris, the diagnosis of papillary
muscle dysfunction would be unlikely.21 Other
disease processes with similar findings such as
valvular aortic stenosis, mitral regurgitation, ven-
tricular septal defect and functional murmurs
have to be excluded by cardiac catheterization.

The history and physical findings in IHSS are
characteristic but not diagnostic. There is still
justifiable controversy as to the cause of the pres-
sure gradient in the left ventricle in certain cases,
especially if the obstruction cannot be demon-
strated by angiographic studies. The therapeutic
modalities, both surgical and medical, are at best
only moderately successful.

SUMMARY

A patient with IHSS who gave a history of a
murmur for 17 years and symptoms of angina
pectoris for two years is presented. A positive
double Master’s two-step was obtained and
seemed to support a diagnosis of arteriosclerotic
heart disease with angina pectoris. The initial
catheterization did not demonstrate the defect.
However, it was apparent on second study. ***

1600 Monroe St. (39180)

REFERENCES

1. Brock, R. C.: Functional Obstruction of the Left
Ventricle, Guy’s Hospital, Rep. 106:221, 1957.

2. Frank, S.; and Braunwald, E.: Idiopathic Hypertro-
phic Subaortic Stenosis: Clinical Analysis of 126

108

JOURNAL MSM A

Patients with Emphasis on the Natural History,
Circulation 37:759, 1968.

3. Wigle, E. D.; Heimbecher, R. D.; and Gunton,
R. W.: Idiopathic Ventricular Septal Hypertrophy
Causing Muscular Subaortic Stenosis, Circulation
26:325, 1962.

4. Horlich, L.; Pethovick, W. J.; and Bolton, C. F.:
Am. J. Cardiol. 17:441, 1966.

5. Brent, L. B.; et al: Familial Muscular Subaortic
Stenosis, Circulation 21:167, 1960.

6. Kupic, E. A.; and Abrams, H. L.: Supravalvular
Aortic Stenosis, Am. J. Roentgenol. 98:822, 1966.

7. Kelly, D. T.: Results of Surgery and Hemodynamic
Observations in Muscular Subaortic Stenosis, J.
Thoracic and Cardiovascular Surg. 51:353, 1969.

8. Hancock. E. W. : Differentiation of Valvular, Sub-
valvular, and Supravalvular Aortic Stenosis, Guy’s
Hosp., Rep. 110:1-30, 1961.

9. Braumwald, E.; and Ebert, P. A.: Hemodynamic
Alterations in Idiopathic Hypertrophic Subaortic
Stenosis Induced by Sympathomimetic Drug, Am. J.
Cardiol. 10:4-89, 1962.

10. Brachfeld, N.; and Gorlin, K.: Subaortic Stenosis;
Revised Concept of Disease, Medicine 38:415, 1959.

11. Criley, I. M.; et al: Pressure Gradients Without
Obstruction, Circulation 32:881, 1965.

12. Braunwald, E.; et al: Hypertrophic Subaortic Ste-
nosis-Broadened Concept, Circulation 26:161, 1962.

13. Mason, D. T.; Braunwald, E.; and Ross, J.: Effects
of Changes in Body Position on the Severity of
Obstruction to Left Ventricular Outflow in Idio-

pathic Hypertrophic Subaortic Stenosis, Circulation
33:374, 1966.

14. Morrow, A. G.; and Brochenbrough, E. C.: Sur-
gical Treatment of Idiopathic Hypertrophic Sub-
aortic Stenosis: Technic and Hemodynamic Results
of Subaortic Ventriculomyotomy, Ann. Surg. 154:
181, 1961.

15. Dobell, A. R. C.; and Scott, H. J.: Hypertrophic
Subaortic Stenosis: Evaluation of Surgical Technic,
I. Thoracic and Cardiovascular Surg. 47:26, 1964.

16. Kirhlin, J. W.; and Ellis, F. H.: Surgical Relief of
Diffuse Subvalvular Aortic Stenosis, Circulation 24:
739, 1961.

17. Morrow, A. G.; Coslas, T. L.; and Braunwald, E.:
Idiopathic Hypertrophic Subaortic Stenosis: Opera-
tive Treatment and Results of Pre- and Postopera-
tive Hemodynamic Evaluation, Circulation 30,
Supp. No. 4:120, 1964.

18. Manchester, G. H.: Muscular Subaortic Stenosis,
New England J. Med. 269:300, 1963.

19. Braunwald, E.; Brockenbrough, E.; and Frye, R.:
Studies on Digitalis: Comparison of the Effects of
Ouabain on Left Ventricular Dynamics in Valvular
Aortic Stenosis and Hypertrophic Subaortic Steno-
sis, J. Am. Heart Assn. Circulation 25:166, 1962.

20. Flam, M. D.; Harrison, D. C.; and Hancock, E. W. :
Muscular Subaortic Stenosis: Prevention of Outflow
Obstruction with Propranolol, Circulation 38:846,
1968.

21. Phillips, J. H.; Bench, G. E.; and De Pasquale,
N. P.: The Syndrome of Papillary Muscle Dysfunc-
tion: Clinical Recognition, Ann. Int. Med. 59:508,
1963.

GROSS AND MICROSCOPIC

There are some very small towns in Mississippi. In one such
community, a favorite pastime on Saturday night is to go to the
local motel and see who rented the room. In fact, this community
is so small that it has only one yellow page in the telephone di-
rectory.

MARCH 1970

109

Changing Methods
And Changeless Principles

WILLIAM K. KELLER, M.D.

Louisville, Kentucky

A workable quote concerning history says, in
effect, that those who refuse to read or attempt to
understand history, are doomed to relive it. The
Greeks, at the time of the Republic, have a great
counterpoint in segments of America today. They
believed that troublemakers, dissidents, and oth-
er nonconformists should simply be annihilated.
They were rarely interested in segregation or in-
tegration, only permanent removal of the insur-
gents and even of some of the too radical think-
ers. Socrates wrote of the group of young people
who had no apparent goal in life, were dissolute
in mind and body, and had no respect for “the
establishment,” their elders, and, rather especial-
ly, their own parents.

When Rome was at the peak of its power in
the then known world, it was certainly as afflu-
ent as American society is now. Some believe it
was the most affluent civilization ever, but they
had their have-nots. As the easy life came to
more and more people, the incentive to work, to
be responsible for one’s self, or to care for anyone
else, decreased in proportion. Eventually, people
being what they are, the division between the
haves and the have-nots became greater, and
those who had more got more and those who had
less got less. This readily led to a greater dissatis-
faction among the have-nots, who began to de-
mand a greater share of the affluence and less re-
sponsibility for the acquiring of worldly goods.
One group even demanded, and got, back pay-
ment for past injustices. Eventually, to capsule
significantly, the have-nots developed a leader-
ship which did indeed obtain for them a greater
and greater share of what was around and things

From the Department of Psychiatry, University of

Louisville School of Medicine.

Read before the Mississippi Psychiatric Society, Jack-

son, Nov. 22, 1969.

1 10

changed radically. In short, Rome fell. There are
parallels aplenty, but modern leadership must do
its homework in history to find short cuts to to-
day’s seemingly new and overwhelming prob-
lems.

“ Methods change; principles never do,”
said the Rev. William Slider. The author
elaborates on this axiom, concluding that
while medical techniques may change, the
principles set down by Hippocrates remain
the same. He advises physicians to stand
firm by these ideals while advancing the sci-
ence and art of medicine as far as humanly
possible.

In the magazine section of the Louisville Cour-
ier Journal and Times, June 15, 1969, there was
an article entitled “All Right, Youth, Make Some-
thing of It,” written by John Ed Pearce, a father
of five, who lived through the depression and the
world’s worst war. With his permission, I will
quote from it, for I feel he has stated the case so
very well :

“I have heard and read a great deal lately
from you young people about your disillu-
sionment with your world, your society, my
generation. You complain that you have
been dumped into a society of war, poverty,
injustice, and prejudice. We have been so
materialistic, you say, that we have forgot-
ten the real values of life — love, fairness,
peace, and brotherhood. As a result of our
greed and timid conformity we have missed
life, and in the process have left you a mess

JOURNAL MSMA

that can only be righted by destroying it and
building better on the rubble.

“I don’t see it quite that way. I offer no
apologies for my generation. I am proud of
it, and of what we have built on the foun-
dation left us. I hope you will do as well.
You will if you will leaven your zeal with a
little humor, your egotism with a little his-
tory, and ask why your insistence on uni-
versal love seems so often to express itself in
hate for those who differ with you.

“We have given you a basically sound
world; imperfect, full of flaws springing from
human imperfections, but strong, dynamic
and exciting.

“It is strange that yours should be the
most favored generation in history and yet
the most self-pitying.

“You speak of poverty, but you have
never been really hungry.

“You are angered — and you should be —
about unemployment, poor job opportunities
for Negroes, economic injustices, dishonesty
in government, the Vietnam war.

“The failings of the past do not justify
those of today, of course. But a realistic
comparison reveals a continuing progress
that is not a symptom of a sick society.

“Because of our so-called materialistic
greed, you are the biggest, tallest, healthiest,
brightest, handsomest generation to inhabit
this land, and perhaps the world. You are
going to live longer, suffer sickness less of-
ten, work fewer hours, learn more, see more
of the world’s grandeur and have more
choice of your life’s undertaking than any
generation before.

“Please try to evaluate the progress made
in the last 20 years in all these areas and to
see how decently we fell into the unwanted
Vietnam war. We do worry about you be-
cause you seem more intent upon destroying
the system than in correcting it. Your in-
terest in violence resembles the storm troop-
er more than the reformer. Are the ideals of
liberty and justice for all less inspiring be-
cause we, being human, fall short of them?
We think not, but it is in the field of social
relationships that we, like all before us, have
fallen shortest of the goal. We have devel-
oped weapons that can end all life (nuclear
power can be made to serve man as well as
destroy him) and the questing mind cannot
be asked to draw back from knowledge be-
cause it may prove dangerous.

“We have not found an alternative to
war. Perhaps you can perfect the social

MARCH 1970 Cl

mechanism so that all men may, without
the threat of force, pursue their course, in
which we will no longer need laws or police
to enforce them, or armies to prevent men
of one belief from trespassing against others,
though the violence with which you protest
violence justifies little hope that you will.

“It is good to know what went on before
so that you can better decide where you
want to go. The apple does not fall very far
from the tree and the traits you have in-
herited are those on which you must depend
as you build your world.”

GLIMMER OF HOPE

All is not lost, however. The following is an
excerpt from a letter written by a young college
drop-out from his duty station aboard an air-
craft carrier off Vietnam:

“Dear Mother and Dad:

“. . . While I am slowly growing older
chronologically and physically, I am moving
by leaps and bounds emotionally. The Navy
has forced or drawn from me and brought to
the surface something which has always
been a part of me, but unfortunately never
utilized constructively. I am speaking of my
inheritance. I sincerely believe I am con-
stantly developing many traits and habits
which are personal assets and essentials to
any young person set on success in a chal-
lenging business world and our fast chang-
ing social environment.

“I thank everyone in our family for the
examples they set, and now it is my turn to
outline some goals for myself to prove that
your love and guidance have been wise in-
vestments.

“With much love,

“Bill”

SQUARE ASTRONAUTS

One wonders if there is any significance in the
fact that the first American in space and the first
man to set foot on the moon were both real
squares — complete with conformity, happy mar-
riage, family formation, education, religion, and
haircuts — who, in their youth, had even been
Eagle Scouts!

The world is bigger, there are more people,
there is outer space, and the atomic bomb, but
the problems and the principles involved remain
the same.

The University of Louisville School of Medi-
cine still requires the recitation of the Hippo-

111

CHANGING METHODS / Keller

cratic Oath upon graduation. It has been modi-
fied a tiny bit, but, in essence, it is the same oath
which has been in use for more than 2,500 years.
Its survival is due to the fact that the principles
which it contains remain the same today as they
were 25 centuries ago. In Greece, when Hip-
pocrates and his colleagues formulated this oath,
there were no instant communication, satellites,
television, or automobiles and super-highways,
but they managed, in an infinitely smaller area,
to pass the word, to differ, to kill, and to get
themselves killed. There were changes, a grow-
ing commercial effort, a changing social picture,
and confused political ideologies. There were ri-
valries among the Greeks which resulted in street
fighting wars between sections. The armies of
Persia were not as far away as Vietnam; they
were poised on the very perimeter of the Greek
states. All these things were going on when the
Oath was formulated. As the Rev. William Slider
said, “Methods change; principles never do.”

HIPPOCRATES’ PRINCIPLES

Hippocrates made many astute observations,
and many are just as valid today as they were
when he first set them down. Some of his con-
clusions were and are correct, most are not.
Some suggested causes of disease and remedies
are hopelessly erroneous, but the principles at-
tendant upon patient care are the same. Hip-
pocrates would hardly believe a recounting of a
heart transplant and probably would question the
sanity of a colleague who described an artificial
kidney, but it is quite certain he would be very
involved and interested in the ethics surrounding
such procedures. The society in which we prac-
tice, the terms we use, the information available,
the advanced equipment — all these have changed
since the day of the Greek physician, but the
ideals, the principles which created the society in
which medicine has come to its greatest achieve-
ment, the fundamentals of the system which
brought about the technical skills and the hu-
manitarian drives which have made medicine
what it is today — these are unchanged. In an era
which is crying to overturn everything, in an age
which is sneering at all that has gone before, it is
well to remember that what is true of medicine is
true of all else.

ONLY METHODS CHANGE

New ways of doing things and new solutions
for problems may be found but these are all es-

sentially technical or mechanical. Physicians must
not be caught up by the transient voices which
point to the discoveries and the technical ad-
vancements in the medical profession and say
that since these outer things are changing, all
must change. It is the physician’s responsibility
to combine the new and the old; in some things
it is deadly to hold back and refuse to move out,
and in others it is just as fatal to attempt to
change, to destroy or to replace. The physician’s
responsibility must be to guard constantly the ba-
sic morality brought down to us from the Island
of Cos so many hundreds of years ago. The Tem-
ple is gone, the landscape has changed, all the
teachers are long dead, but the ideal is still here,
and a thousand years hence, when the moon is a
colony and Mars a staging base for an assault up-
on the galaxies, it is certain that physicians will
be able to take the same oath and its words will
be as meaningful as today. All medical science
and all the physican’s skills cannot make man
happy, secure, or make him at last immune to
death. It is that other dimension to dealing with
patients which strives to achieve these things,
and its essence is in that ancient vow. It is the
need of mankind for affection, respect, and for
hope, and finally for the courage to make the
last trip when art and science have finally failed.
Indeed, methods change, but principles never do.

QUESTIONING ATTITUDE

It is the physician’s responsibility further to
remain concerned with the plight of his fellow-
man and he must be his brother’s keeper. How-
ever, this effort must remain in his field of com-
petence. If physicians do not retain a healthy
questioning attitude toward their patients and
themselves, they will surely wind up with a series
of pat and, to them, acceptable answers, firmly
convinced that the world is almost entirely popu-
lated with “neurotics.” “He has eyes and sees
not” — this description just must be a properly
directed scold to all of us. In terms of time, the
fact that blood circulated was discovered only
yesterday; yet how could it not have been appar-
ent for so long? Who looked and didn’t see?

My father, who was a general practitioner, had
a notebook of his lectures at the University of
Louisville in 1893. In one place, under the head-
ing “Malaria” there is this notation: “Malaria is a
very debilitating disease, caused by a miasma
which arises from swampland in the summer,
after dark. The symptoms are of an acute onset
of chills, followed by a high fever, then a pro-
fuse sweat. The treatment is quinine sulphate,

112

JOURNAL MSMA

gr. V every three hours for six days, then . . .
etc.”

PHYSICIAN OMNISCIENCE

It is an amusing fantasy to wonder how many
physicians around the world took careful histo-
ries and made many observations to come up
with the fact that this disease only occurred in
patients who had been out at night, around
swampland, in the summertime. They even knew
how to cure it. But the most fun is to conjure up
an image of those same astute physicians stand-
ing on the edge of some watery area, at night, in
the heat, and seeing only the miasma arising as
they swatted mosquito after mosquito.

How many mosquitoes are being swatted to-
day while a physician decides in his own om-
niscience that this particular patient’s problems
and symptoms arise from some familiar miasma.

No other branch of medicine is given — or
takes — credit for so much knowledge about ev-
erything as does psychiatry. We psychiatrists
know what causes unrest, revolt, hippies, draft
card burnings, racism, crime and just about ev-
erything else which is wrong in the world. We
have fostered a permissiveness with a plea for
“understanding” which makes most any kind of
behavior understandable, and consequently ac-
ceptable. Not all of us are guilty, of course, but
too many are.

Psychiatry’s professional jargon has been
loosed on the world in a completely unbridled
manner. Psychiatrists are often flattered by an
inquiry into making some really rather silly pro-
nouncements which have nothing to do with per-
sonal experience, knowledge, or training. They
give first their opinion as a human being based

upon some experience with a few people who
may or may not have had the same or similar
problems. How much does training in medicine
fit them to know how to cure the political, cul-
tural or sociological ills of the world? They should
be involved and concerned and help in every
way, but stick to their lasts as regards real knowl-
edge beyond their training and experience. They
should leave many educated guesses to others.
Psychiatry has not cleaned its own Augean sta-
bles in spite of all its Herculean efforts. They are
still too full for comfort or complacency. Schizo-
phrenia is still around, you know.

If one asks the average psychiatrist how to
build a cantilever bridge, he may tell you of the
cantilever principle, but then withdraw into a
happy fortress of avowed ignorance concerning
the technical knowledge required to do the job.
Ask him what causes racism, crime in the streets,
juvenile delinquency, student unrest, and then
get out of the way, for here it comes! Then ask
him what to do about it and you will get more
answers. Be kind and don’t ask him why these
problems continue to increase in spite of his
Olympian understanding.

Psychiatrists must learn to rely on those who
are trained and capable in a specific area to do a
special job. Publicity concerning the disci-
pline has been so great that psychiatrists have
begun to believe it themselves. The simple phrase
“I don’t know” rusts from lack of use. It seems
that we would be well advised to get hooked on
some “humble pills” and stick to the business of
being a physician. Indeed, methods change, but
principles never do. ***

323 E. Chestnut St. (40202)

TREAD LIGHTLY

A hippie presented himself at the physician’s office, attired in
the way-out regalia of the cult. The receptionist, noting his wear-
ing only one shoe, asked:

“Did you lose a shoe?”

“No,” retorted the hippie, “but I just found one.”

MARCH 1970

1 13

Radiologic Seminar XCIII:
Inferior Vena Cavography

OTTIS G. BALL, M.D.
Jackson, Mississippi

This is a simple, safe, and often very informa-
tive procedure that can be performed fairly
quickly and requires no special equipment.

It is helpful to incorporate this study with ex-
cretory urography for evaluation of pelvic or
abdominal masses, particularly in infants and
children. However, it is also useful in adults as an
aid to determine the extent of lymphomas, car-
cinoma of the uterus, prostate, testicle, and colon.
Conceivably, it may also be helpful in evaluation
of tumors of the liver and pancreas.

The inferior vena cava returns to the heart
blood from parts below the diaphragm. It is
formed by the junction of the two common iliac
veins on the right side of the fifth lumbar ver-
tebra. It is usually straight, and lies slightly to
the right of and parallel to the lumbar spine (see
Fig. 1 A and B). It occupies about 15 per cent
of the retroperitoneal space. Lymphatic vessels
and nodes draining the pelvis and abdomen are
in juxtaposition to the inferior vena cava through
its course in the retroperitoneal space. The right
kidney and adrenal gland border on its right
lateral aspect. The right renal artery often pro-
duces a sharp indentation on the posterior bor-
der of the inferior vena cava at the level of the
second lumbar vertebra. The second and third
portions of the duodenum and the head of the
pancreas lie against the anterior border. The
caudate lobe of the liver may impinge upon the
vessel superiorly and anteriorly.

Inferior vena cavography is performed by in-

Sponsored by the Mississippi Radiological Society.
From the Department of Radiology, Mississippi Baptist
Hospital.

1 14

Figure 1A. Anteroposterior view of opacified in-
ferior vena cava. Note washout effect (arrow) due to
entry of renal vein.

JOURNAL MSMA

Figure 2. Complete obstruction of right common
iliac vein with extensive collateral circulation. Note
non-functioning right kidney and normally function-
ing left kidney.

an adequate guide for the placement of cobalt
ports. A repeat study four weeks following radi-
ation therapy showed a patent right iliac vein
and vena cava and a functioning but somewhat
small right kidney.

In summary, inferior vena cavograms are
easily performed procedures that are helpful in
evaluation of the retroperitoneal space in regard
to primary or metastatic tumors involving the
lymph nodes or other structures in this area.
They are simpler than lymphangiography as a
means of assessing retroperitoneal lymph nodes.
They are more informative than gastrointestinal
studies or intravenous urography alone. ***

1151 North State Street (39201)

BIBLIOGRAPHY

1. Gray, Henry: Anatomy of the Human Body, Phila-
delphia, Lea and Febiger, 1954.

2. Hillman, D. C., and Tristan, T. A.: Inferior Vena
Cavography in Detection of Abdominal Extension of
Pelvic Cancer. Radiology 81:416-427, 1963.

3. Holtz, S., and Powers, W. E.: Inferior Vena Cavo-
grams. Radiology 78:583-590, 1962.

4. Tucker, A. S.: The Roentgen Diagnosis of Abdominal
Masses in Children. Amer. J. of Roent. 95:76-90,
1965.

serting a 17 or 18 gauge needle or a catheter into
one or both femoral veins and injecting 30 to 50
cc. of 50 per cent Hypaque, or its equivalent,
rapidly. First, a cross-table lateral exposure is
made with the patient in a supine position. This
is done so that contrast media will be present in
the urinary tracts and visualized in relationship
to the vena cava on the anteroposterior projec-
tion. A second injection is performed and an an-
teroposterior view is obtained.

Figure 2 is an AP view of an inferior vena
cavogram that reveals extensive venous ob-
struction and blockage of the right ureter. This
was a sixty-two year old white male patient with
edema of the scrotum and right lower extremity.
Biopsy of a pelvic node revealed lymphosarcoma.
Cobalt therapy was given to the pelvis and retro-
peritoneal node areas. The venogram furnished

Figure IB. Lateral view of opacified inferior vena
cava with stippled borders added for easier identifi-
cation. Again , note defect (arrow) due to entry of
renal veins and posteriorly located renal artery
defect.

MARCH 1970

115

The President Speaking

‘Or Lose by Default’

JAMES L. ROYALS, M,D.

Jackson, Mississippi

-

There has never been a time in American history that has seen
more drastic changes brought to the health care delivery system.
Never has American medicine been under such attack as it is
now. Lost in this rush for change is the fact that Americans en-.-
joy the best medical care in the history of the world. Those who
would socialize American medicine and make physicians ser-
vants of the state are hard at work as never before.

The next big push towards socialism will be made in an effort
to bring about compulsory national health insurance for all
Americans. AMA’s answer to this move is a voluntary system of
tax credits, which has been labeled Medicredit. Looming on the
horizon, probably in 1972, is a great debate over these plans. It
is necessary that physicians inform themselves well in every as-
pect of these plans so that they may effectively contribute to the
debate. Much informative material is being published at intervals
in the Journal and in many other medical publications.

The nature of a physician’s work tends to isolate him from en-
vironments that actively consider the socioeconomic aspects of
these plans. It is, therefore, necessary that we make an extra ef-
fort to become well informed on these major issues, or lose by de-
fault to those who would remove free enterprise from the prac-
tice of medicine. ★★★

116

JOURNAL MSMA

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 3
March 1970

Invasion of Privacy:
New Angle on Smoking

i

The jumbo jets opening a new generation of
travel, Pan Am’s Boeing 747’s, bring back mem-
ories of the great trains of the 1920’s. As in the
wonderful old Pullman car, there are sections of
the big plane in which smoking is not permitted.

The Wall Street Journal reports that since non-
smoking President Nixon’s first press conference,
these hitherto smoke-filled room sessions have
been tobacco-free. Consumer crusader Ralph Na-
der has petitioned the Federal Aviation Admin-
istration and the Interstate Commerce Commis-
sion to prohibit smoking altogether on air lines
and busses. He also wants puffing outlawed in
hospitals and other public accommodations.

The U. S. Air Force surgeon general has is-
sued orders forbidding smoking by any hospital-
ized patient, and no USAF hospital or BX in a
hospital complex sells cigarettes. And conspicu-
ously missing among vending machines at the
Mississippi State Medical Association’s head-
quarters building in Jackson are those dispensing
tobacco. We’ll take your dime for a Coke, cook-
ies, peanuts, and candy bars, but tobacco prod-
ucts are unavailable. Smoke if you’ve got them,
but we won’t help.

II

These are signs of the times catching up to
the long suffering of nonsmokers caught in a

tobacco smog. Antismoking advocate John Ban-
zhaf, III, of Washington, the young attorney who
forced the free equal time for the case against
smoking on television (ASH: Mild Label for a
Singeing Movement, J.M.S.M.A. X:99-100
(March) 1969), uses lawsuits to hang up no
smoking signs in elevators, public transportation,
and facilities deemed to be in interstate com-
merce.

In fact, Mr. Banzhaf now heads a second or-
ganization called CRASH. That's “Citizens to
Restrict Air Line Smoking Hazards.” His orig-
inal organization which shook up the TV industry
is ASH, “Action on Smoking and Health.” Nor
are his words falling on deaf ears, because the
U. S. Public Health Service, in partnership with
FAA, has initiated a one year study of the ef-
fects of tobacco smoke on air line passengers.

One such important passenger, according to
The Wall Street Journal, was no less than the non-
smoking Chief Justice of the United States, War-
ren E. Burger. The Chief Justice was on a flight
from Washington to Minneapolis when he was
literally overcome by fellow passengers’ puffing
away. He got off the plane at Madison, Wis., spent
the night, and finished his trip the next day.

Chief Justice Burger wrote the president of the
air line but according to WSJ, didn’t command
the courtesy of a reply. A subsequent letter to

MARCH 1970

117

EDITORIALS / Continued

FAA brought the Supreme Court chief a prompt
response from the administrator.

III

The new and militant movement against smok-
ing in public accommodations and especially in
cramped, close transportation situations has both
legal and medical overtones, and these are in-
terrelated. Some individuals are allergic to tobac-
co smoke, and nearly all nonsmokers find it of-
fensive in varying degrees.

So for those to whom smoke may not be a
health hazard of immediate consideration there
may be a legal remedy. Messrs. Nader and Ban-
zhaf contend that uncontrolled smoking consti-
tutes an invasion of privacy. Moreover, it is con-
tended that all have a right to breathe air un-
contaminated by tobacco smoke.

Sen. Mark Hatfield (R., Ore.) and Rep. Andrew
Jacobs (D., Ind.) have introduced bills in the
Congress to restrict smoking aboard public trans-
portation. The measures will doubtless have the
unremitting support of many physicians, if a
sampling of the letters to American Medical News
recently against smoking in airplanes is any bell-
wether.

Italian investigators claim that free, uninhaled
fumes from cigarettes may constitute a health
hazard to nearby nonsmokers. They argue that
during the mean burning time of a cigarette
which is 12 minutes, it is inhaled only 24 sec-
onds, leaving more than 1 1 minutes of smoke
production for the distress of in-range nonsmok-
ers.

IV

In a letter to Sen. Hatfield, reports WSJ, a
manufacturer of the new big jet aircraft said that
electronic pressure controls are now being used
instead of the old pneumatic controls. The plane
maker said that the electronic controls are ad-
versely affected by tobacco tar. While FAA has
yet to identify a hazard to air materiel opera-
tions safety attributable to cigarettes, we may
reasonably postulate that they don’t help in the
slightest.

Society has become acutely consumer con-
scious, and caveat emptor is fast changing to
caveat vendor. The smoker has no particular
claim on anybody else’s airspace, and the fact of
the matter is that man’s natural state is not to
smoke. Most would, however, seek a reasonable
solution to the annoyances and vexations of the

puffer of the el hempo corona in the hotel ele-
vator before breakfast, even if one of four ele-
vators had to be dedicated to the polluters of air
and lungs.

We wish smokers no ill, for they have enough
woe already. We simply wish nonsmokers well
with as much fresh air as is currently available.
In fact, common courtesy should make laws, regu-
lations, and lawsuits quite unnecessary as Amer-
ica slowly comes to its senses about tobacco and
health. — R.B.K.

A Punitive Bill
Aimed at Physicians

At a time when the professional liability pic-
ture in the United States is darkest, House Bill
407 has been dropped in the hopper of the Regu-
lar Session of the Legislature at Jackson. The mea-
sure, by Reps. James Simpson of Pass Christian
and Charles Bullock of Gulfport would, if passed,
eliminate the requirement for corroborative med-
ical testimony in proof of negligence, failure to
exercise reasonable care, caution, or professional
skill.

The bill would permit awards to plaintiffs in
malpractice suits against physicians “by juries on
the basis of (nonmedical) testimony offered in
evidence, notwithstanding any precedents estab-
lished by any decision heretofore rendered.”

The net result is to deny the defendant doctor
part of his defense, and nobody is foolish enough
to believe that plaintiffs in these cases now have
the laws and courts stacked against them. What
this bill does is introduce into our Mississippi law
books the liberal doctrine of res ipse loquitur
(the thing speaks for itself).

If passed. House Bill 407 could cause the
premium on professional liability insurance for
physicians in Mississippi to zoom as it has in oth-
er states. The ultimate, extreme consequence
would be to drive this vital insurance coverage
from the market.

In California where the laws are liberal and
the courts are more so, physicians pay anywhere
from $2,500 to $20,000 a year in professional
liability insurance premiums. It is almost a rule
of thumb that the coverage costs around $1,500
in most other states. We have been extremely
fortunate in Mississippi, because we have the
lowest premium in the nation.

This is not to say that physicians are ganged
up against lawful claims, throttling the courts,

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JOURNAL MSMA

and stacking the deck. Judicial records indicate
exactly the opposite. But to erect a climate deny-
ing a physician part of his basic right of defense
is something else — something which is neither
just nor reasonable. This is dangerous legisla-
tion with a potentially punitive impact on phy-
sicians. It should be defeated. — R.B.K.

Restraining Devices
Help Mother Make Sure

The midafternoon traffic near the shopping
center is heavy, and mother is tired from a weary
day as she heads home with the groceries and her
energetic three-year-old standing up on the front
seat. This is the setting for tragedy, an accident
itching to happen, and one that all too frequently
does.

The American Academy of Pediatrics has re-
cently published studies showing that 5,900 chil-
dren under 15 years of age were killed in motor
vehicle accidents in 1969. Many, if not most,
would be alive today had mother made sure
with a restraining device for the child.

Bassinets, safety harnesses, kid-size lap belts,
and a host of devices are readily available, and
AAP demonstrates that these provide “the high-
est degree of dynamic protection” for children in
automobiles. The Academy, through its journal.
Pediatrics, calls on physicians to learn which of
the restraining devices to recommend for children
according to weight and size.

There is a great deal more to safety restraints
for the little people than a bar or a belt. Manu-
facturers have adopted design concepts which
take into account the weight, height, center of
gravity, buttocks-knee length, and body composi-
tion of the child.

“A device should be constructed with regard
to all these factors,” say Drs. Frederic D. Burg.
John M. Douglass, Eugene Diamond, and Mr.
Arnold W. Siegel, writing in Pediatrics, “so as to
prevent ejection of the child and provide a long,
smooth period of deceleration during collision or
sudden braking.”

The report recommends four classifications of
restraining devices for youngsters in an automo-
bile:

— Children from the newborn up to 12 pounds
weight should be transported in a rear seat bas-
sinet or car bed held secure in place by front and
rear seat safety belts. It is important that the
bassinet be parallel to the long axis of the auto-

mobile, with the infant in a feet-forward position.
A properly constructed infant carrier may be
used in the front seat of a car for children in this
weight category in lieu of the rear seat bassinet.

— Children from 12 to 24 pounds should be
placed in a properly constructed rear seat safety
harness or toddler seat.

— Youngsters ranging in weight from 25 to 50
pounds should be placed in a good safety child
seat. The shield-type design is said to afford the
greatest protection, although it has the major
psychological disadvantage of limiting the child’s
field of vision.

— Children weighing more than 50 pounds
should use the adult lap belt, and where height
exceeds 55 inches, the adult shoulder harness
should also be worn.

The American College of Surgeons, the major
medical pioneer in automotive safety through
passenger restraints, says that as many as 10,000
lives may be saved in a year with modern seat
belts and shoulder harnesses. It is possible that
this figure might reasonably be increased if Jun-
ior and Sister are also well-restrained.

Even fatal injuries to infants can happen with
just sudden stops and minor traffic accidents. And
most fatal accidents, the traffic experts tell us,
occur within 25 miles of the victim’s home. So
this business of rationalizing that “we don’t need
to buckle up to go to the shopping center” is an
invitation to tragedy. Let’s take a second to help
mother make sure. — R.B.K.

The Inside Story
on AMA Membership

Just who among American physicians belongs
to the American Medical Association? Doesn’t
everybody? No, not by a long shot, and medi-
cine’s critics have a gleeful field day pointing out
that one out of three American physicians isn’t a
member.

But the facts put an entirely different light on
the figures, and they are worth knowing. AMA's
Department of Records and Circulation, the
membership office, reports that on Dec. 31,
1969, there were 328,366 physicians known to
be in the United States. Of this total, AMA had
219,570 on its rolls. If the examination stops
here, then somebody is badly indicted.

Exactly 199,997 physicians were in private
practice at the year end, and of these 168,082
were members. But the percentage of AMA

MARCH 1970

119

EDITORIALS / Continued

members from among those physicians who are
eligible is much more impressive. Remember that
a physician is AMA-eligible only if he belongs to
his state medical association or is a career fed-
eral medical office eligible for direct service mem-
bership. Of these, 91 per cent are AMA members.

So what about the nonmembers? Obviously,
the largest segment is made up of physicians in
training, interns and residents. About half of the
state medical associations — including Mississippi
— provide for their membership on a dues-exempt
basis, but most are not on the rolls. The second
largest group of nonmembers are those employed
full time by hospitals, some 21,167 from among
whom only 8,224 are AMA members. Medical
school faculties are next with 5,184 on the rolls
from a total of 10,817 in the schools.

The record of AMA membership among pri-
vate practitioners is remarkably good, consider-
ing that it is voluntary in 41 of the 54 state and
territorial medical associations. Of the states with
compulsory AMA membership, New York and
California account for more than 50,000 on the
rolls.

Trite as it sounds, medicine has never before
had a greater need or reason to seek unity. This
does not mean that every member should be a
rubber stamp for the same viewpoint, but it does
mean that all eligible, qualified, ethical physicians
ought to be under their own organizational roof.
With all of its troubles, AMA still remains the
paragon among organizations and associations.

Moreover, AMA is a confederation of the state
medical associations whose collective will directs
its every effort and program. Medicine’s house
ought to have the family living in it. — R.B.K.

The Old Admonition:
Watch Those Narcotics!

Almost every physician grows weary over ad-
monitions about abuse, fraud, and theft of nar-
cotics, and virtually all know the ground rules on
safe, sane, and lawful handling of narcotics. But
the problem gets worse, not better, and a quick
review of the U. S. Narcotics Bureau “Don’ts for
the Practitioner” isn’t a total waste of time.

The drug-oriented subculture in the nation has
not helped the situation in the slightest, and
while the vast majority of drug abuse instances

relate to nonnarcotics, there is still a grave and
growing problem. The addict is a clever, schem-
ing bundle of determination — a challenge to the
most soundly conceived fail-safe methods of
preventing narcotic abuse.

The bureau begins with the age-old warning:
Don’t leave prescription pads lying around in
the office or elsewhere. Not a few of us have
seen Rx pads conveniently distributed as tele-
phone notepads in clinics and offices. Nor should
a physician’s supply of narcotics be unprotected.

Pharmacists tell us that there are some few
physicians who do not use brackets and spelling
when specifying the number of dosage units to
be dispensed in a narcotic Rx. A hastily written
“Morphine HT # 10” can easily become “#100”
in the hands of the addict, and many are expert
forgers.

Few physicians fall for the simulated symptoms
of a condition known to require narcotics, but a
patient who can voluntarily produce bloody spu-
tum is not unknown among addicts. Some women
addicts have successfully posed as nurses, fraud-
ulently securing narcotics or prescriptions for
imaginary patients.

The bureau says that more and more phy-
sicians’ bags are being stolen from automobiles.
A good rule puts the bag in the trunk, and a
minimum amount of narcotics are carried in the
bag. A record of narcotics dispensed ought to be
maintained.

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JOURNAL MSMA

Don’t resent a pharmacist’s call for verification
of a narcotic Rx — he is responsible for forgeries
under federal law. Much of the illicit supply of
narcotics can be cut off from addicts with ob-
servance of these common sense ground rules.
It’s an effort worth making. — R.B.K.

March 6, 1970

CURRENT ADVANCES IN

MANAGEMENT OF DISEASES OF

THE KIDNEY AND THE

URINARY TRACT

University Medical Center, Jackson
March 6, 1970, beginning at 8:30 a.m.

Sponsored by the Mississippi Kidney Founda-
tion and The University of Mississippi
School of Medicine, Department of Medi-
cine, Division of Urology

Participants:

H. Earl Ginn, M.D., associate professor of medi-
cine, urology and biomedical engineering and
chief of the nephrology division, Vanderbilt
University School of Medicine, Nashville, Ten-
nessee

Donald B. Halverstadt, M.D., department of
urology, University of Oklahoma Medical Cen-
ter, Oklahoma City, Oklahoma

Eugene C. Klatte, M.D., chairman of the depart-
ment of radiology, Vanderbilt University
School of Medicine, Nashville, Tennessee

Herbert G. Langford, M.D., professor of medi-
cine, The University of Mississippi School of
Medicine

Friday Morning

Pathologic Physiology of Medical Renal
Disease
Dr. Ginn

Pathologic Physiology of Surgical Disease
of the Urinary Tract
Dr. Halverstadt

Current Techniques of Radiologic Evalua-
tion of the Urinary Tract
Dr. Klatte

Treatment of Preterminal Renal Failure
Dr. Ginn

Friday Afternoon

Renal-Vascular Hypertension
Dr. Klatte

Diagnosis of Renal Hypertension
Dr. Langford

Management of Renal Hypertension
Dr. Halverstadt

Case Presentation, Questions and Gener-
al Discussion

March 16-20, 1970

NEUROLOGICAL DISEASES AND
STROKE INTENSIVE COURSE

University Medical Center, Jackson
March 16-20, 1970, beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Participants:

Robert D. Currier, M.D., professor of medicine
(neurology) and co-director of the stroke unit,
The University of Mississippi School of Medi-
cine

Robert Smith, M.D., assistant professor of neuro-
surgery and co-director of the stroke unit, The
University of Mississippi School of Medicine

Registrants in this one-week intensive course
will review management of acute stroke pa-
tients, severe head injuries, seizure problems
and other neurological and neurosurgical dis-
orders. In addition to seminars, rounds, group
discussions, and assigned reading, registrants
will participate in the daily care of patients in
the Mississippi Regional Medical Program
demonstration stroke unit.

March 16-20, 1970

CARDIOLOGY INTENSIVE COURSE

University Medical Center, Jackson
March 16-20, 1970, beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Participant:

Patrick H. Lehan, M.D., professor of medicine
and Mississippi Heart Association William D.

MARCH 1970

121

POSTGRADUATE / Continued

Love research professor of cardiology, The
University of Mississippi School of Medicine

This one-week intensive course will famili-
arize physicians with current concepts in bed-
side diagnosis of heart disease. Pulse tracings,
electrocardiograms, hemodynamic data and
other cardiovascular aids will be used to re-
view practical points of physical diagnosis and
various forms of heart disease. Participants will
witness cardiac catheterizations and join the
cardiovascular team’s discussion on manage-
ment of patients.

Both intensive courses will be limited to five
physicians from the class of 20 enrolled in
the four-year Mississippi Postgraduate Institute
in the Medical Sciences, supported by the Mis-
sissippi Regional Medical Program and designed
by The University of Mississippi Medical Cen-
ter and the Mississippi State Medical Associa-
tion.

CIRCUIT COURSES

Southern Circuit

Biloxi- — March 4 — Session 3

Bay-Waveland Yacht Club, 6:30 p.m.
Laurel — March 12 — Session 3

Laurel Country Club, 6:30 p.m.

Session 3 — Current Approach to Tetanus
Prophylaxis and Treatment, Dr. Ray-
mond Martin

Diagnosis and Management of Hypothy-
roidism, Dr. J. Manning Hudson

Eastern Circuit

Meridian — March 3 — Session 1; April 7 —
Session 2, Northwood Country Club,
6:30 p.m.

Session 1 — Carcinoma of the Cervix

Radiologic Approach, Dr. Bernard Hick-
man

Surgical Approach, Dr. Richard Boronow
Session 2 — Respiratory Failure: Current

Methods of Management, Dr. Boyd
Shaw

Surgical Management of Emphysema, Dr.
William Fain

Columbus — April 28 — Session 3

Lowndes General Hospital, 6:30 p.m.
Session 3 — Complications Associated with
Saddle Block Anesthesia in Obstetrics,
Dr. Donald Sherline

The Management of Edema Related to the
Kidney, Dr. Ben B. Johnson

Southwest Circuit

McComb — April 7 — Session 3

Southwest Mississippi General Hospital,
7:00 p.m.

Natchez — April 21 — Session 3

Jefferson Davis Memorial Hospital, 7:00
p.m.

Session 3 — Headache

Neurological Approach, Dr. Armin Haer-
er

Neurosurgical Approach, Dr. Robert R.
Smith

FUTURE CALENDAR

March 2-6, 1970

Nephrology Intensive Course

March 3

Circuit Course, Meridian
March 4

Circuit Course, Biloxi
March 6

Renal Disease Seminar
March 12

Circuit Course, Laurel

o

“Very humorous, Miss Fisher, but just for your
information, it isn’t another false alarm.”

122

JOURNAL MSMA

March 16-20

Cardiology Intensive Course
Stroke Intensive Course

April 1-3

Cardiovascular Seminar
April 7

Circuit Course, McComb
Circuit Course, Meridian

April 16

Mississippi Thoracic Society
April 21

Circuit Course, Natchez
April 28

Circuit Course, Columbus
May 5

Circuit Course, Meridian
May 11-14

Mississippi State Medical Association

Lemann Bounds of Meridian was recently elect-
ed president of the Debonaire Dance Club. Mem-
bers meet once a month for a buffet dinner and
dancing.

Paul B. Brumby of Lexington spoke at the ex-
ecutive board meeting of the Mississippi State
Medical Association Auxiliary in Natchez.

Duane Burgess and Fred Tatum, both of Hat-
tiesburg, participated in the Jan. workshop on
care of the geriatric patient at the University of
Southern Mississippi School of Nursing.

Charles N. Cannon, formerly of Folkston, Ga.,
is now practicing medicine and surgery in Phila-
delphia in the former location of George Day
Studios. Dr. Cannon is a graduate of the Univer-
sity of Mississippi School of Medicine.

Temple Carney of Meridian has joined the
staff of the Rush Medical Group as a general
practitioner. Dr. Carney graduated from the Uni-
versity of Mississippi School of Medicine in 1968.

Robert E. Carter and Guy Gillespie, both
of Jackson, presented a postgraduate circuit course
on anemia to physicians in the coastal area and
at Hattiesburg recently.

Marion E. Cockrell of Laurel and his wife ex-
hibited and lectured on their collection of rub-

bings of English brasses at the Lauren Rogers
Library and Museum of Art in Laurel.

Clyde X. Copeland, Jr., William F. Owens,
Jr., and L. Buford Yerger, Jr., all of Jackson,
have been inducted as Fellows of the American
Academy of Orthopaedic Surgeons at the group’s
annual meeting in Chicago.

Joe S. Covington and Octavius D. Polk, both
of Meridian, have been named to the General
Advisory Council of the Mississippi Medicaid
Commission. Dr. Covington will serve as chair-
man of the Physician’s Services Technical Ad-
visory Committee.

Robert D. Currier, A. F. Haerer, and Rich-
ard W. Naef, all of Jackson, have been awarded
certificates of merit by the National Council on
Epilepsy for service during the past year. The
three physicians are members of the board of the
Mississippi Council on Epilepsy.

James Robert Giffin of Louisville has been re-
elected to active membership in the American
Academy of General Practice upon completing
150 hours of accredited postgraduate work in the
last three years.

Stanislaw Grabowski, a native of Poland, has
joined the staff at Ellisville State School as a
physician in the medical department.

James D. Hardy of Jackson reigned as King of
the Junior League’s 1970 Carnival Ball in Janu-
ary. The title is given annually to those the
League honors for their vital contributions to
mankind.

Karl Hatten of Vicksburg received the Dis-
tinguished Service Award of the Vicksburg Jay-
cees at their banquet at the Downtowner Motor
Inn.

Martha Hays of Gulfport is now serving as a
full-time clinician at the Harrison County Health
Department.

Henri Melvin Hedgewood, formerly with the
U. S. Navy at Pensacola, Fla., has begun the prac-
tice of medicine at Raleigh. The general practi-
tioner is a member of the medical staff of Smith
County General Hospital.

Jack C. Hoover of Pascagoula will serve as
president of the American Cancer Society of Jack-
son County for 1970.

Gerald Hopkins of Oxford recently spoke on
“Heart — the Number One Killer” at the District
Five Heart Association’s annual Heart Fund
dinner meeting at the Water Valley Country Club.

MARCH 1970

123

PERSONALS / Continued

Edley Jones, Sr., of Vicksburg has been saluted
by the Vicksburg Evening Post as a civic leader
holding places of responsibility in the business,
cultural and civic life of the city.

Dewey Hobson Lane, Jr., of Pascagoula has
been named Pascagoula’s outstanding young man
for 1969. The surgeon was selected from six
nominees for the award, based on community
service.

Ray Lee of Liberty has announced that he will
be a Republican candidate for the Third Missis-
sippi District seat in the United States Congress.

Lawrence W. Long of Jackson has been selected
to head a state committee to launch a campaign
to honor retiring Selective Service director Gen.
Lewis B. Hershey. Dr. Long was director of the
Selective Service System in Mississippi during
World War II.

William E. Lotterhos of Jackson delivered
the dedicatory address at the dedication cere-
monies and tour of the facilities of Leake County’s
new $600,000 Extended Care Unit at Leake Me-
morial Hospital.

John McFadden of West Point is currently serv-
ing as a director for the West Point Jaycees.

Robert L. McKinley, Jr., of Tupelo recently
appeared on WTWV television as a guest of Mrs.
Hugh Purnell on the health program. Dr. Mc-
Kinley spoke on drugs and narcotic abuse.

Patricia Moynihan of Jackson and UMC spoke
on Tissue Compatibility before the District Nine
Heart Association’s annual dinner at the Buena
Vista Hotel in Biloxi.

J. R. Mullens, Jr. of West Point was unani-
mously re-elected to serve another year as Chief
of Staff of Ivy Memorial Hospital.

J. K. Oates, Jr. of Jackson announces the removal
of his office to Suite 482, Hinds Professional
Building, 1815 Hospital Drive, Jackson.

J. T. Prescott, formerly of Central Valley,
Calif., has begun the practice of medicine in
Osyka. He will be affiliated with the Schilling
Memorial Hospital there.

Curtis D. Roberts of Brandon has received the
insignia of colonel in ceremonies of the Missis-
sippi Air National Guard in Jackson. Dr. Roberts is
the first Mississippi Air Guard flight surgeon to
reach the rank of colonel.

Lewis J. Rutledge has joined in a partnership
with Verner S. Holmes to form the Southwest
Mississippi Ear, Nose and Throat Clinic at 405
Marion Avenue in McComb.

Robert T. Surratt of Jackson was named coun-
cilor from Mississippi for the American College
of Radiology. C. D. Bouchillon, III, of Laurel
is alternate councilor. Each physician was elected
to his post by the Mississippi Radiological Society.

Walter Treadwell, Richard Johnson, Boyd
Shaw, and Rush Netterville, all of Jackson,
recently participated in the 14th annual Tri-
State Thoracic Society Case Conference in Biloxi.

Nancy Varnado of Jackson, Central Medical
Society’s executive secretary, and Rowland B.
Kennedy, MSMA executive secretary, attended
the AMA-sponsored meeting of senior medical
executives in Chicago.

E. A. White, III of Corinth has been named
Outstanding Young Man of 1969 by the Corinth
Jaycees at their annual Distinguished Service
Award banquet.

John Wofford of Greenwood was one of the
principal speakers at the “Hearts and Husbands”
program sponsored by the LeBonte Woman’s
Club at the Greenwood Little Theatre. Dr. Wof-
ford is currently serving as president of the Le-
flore County Heart Association.

William L. Wood, Jr. of Tupelo instructed stu-
dent nurses at Tupelo’s Northeast Mississippi
Junior College School of Nursing in the tech-
niques of cardiopulmonary resuscitation. Dr.
Wood, president of the Lee County Heart As-
sociation, limits his practice to internal medicine.

Rhea L. Wyatt of Holly Springs has been ap-
pointed acting health officer for Lee County to
succeed H. K. Tatum, who resigned for reasons
of health.

Fox, James Herman, Jackson. M.D.,
Memphis Hospital Medical College, Mem-
phis, Tenn., 1903; interned U. S. Marine Hos-
pital, Memphis, Tenn., one year; dermatology
residency, Jefferson Medical College, Philadel-
phia, Pa., May 1, 1909-July 31, 1909; postgrad-

1 24

JOURNAL MSMA

uate study, Mar., 1945; member MSMA Fifty
Year Club; Emeritus member of MSMA; died
Jan. 8, 1970, age 89.

. Wingo, Oliver Bryson, Sardis. M.D.,
* University of Tennessee College of Medi-
cine, Memphis, Tenn., 1943; interned Norwood
Hospital, Birmingham, Ala., one year; pediatric
residency, same, nine months, 1944; deceased
Jan. 31, 1970, age 51.

The following physicians have been elected to
membership by their respective component Med-
ical Societies in the Mississippi State Medical As-
sociation and the American Medical Association.

Bennett, Kenneth Rhoma, Jackson. Born Ty-
ler, Texas, July 27, 1933; M.D., University of
Texas Southwestern Medical School, Dallas, 1962;
interned Confederate Memorial Medical Center,
Shreveport, La., one year; medicine residency,
same, Nov. 15, 1964-June 30, 1965; medicine
residency. University Medical Center, Jackson,
Miss., July 1, 1963-Jan. 31, 1964 and Sept. 1,
1966-June 30, 1967; cardiology fellowship, same,
July 1, 1967-June 30, 1969; elected Nov. 4, 1969
by Central Medical Society.

Cockrell, Marion Everett, Jr., Laurel. Born
West Point, Miss., July 14, 1937; M.D., Tulane
University School of Medicine, New Orleans,
La., 1962; interned Charity Hospital, New Or-
leans, La., one year; obstetric and gynecology
residency, same, July 1, 1963-June 30, 1966;
elected Dec. 18, 1969 by South Mississippi Med-
ical Society.

Collins, Rex Wilson, Laurel. Born Memphis,
Tenn., Nov. 10, 1938; M.D., University of Mis-
sissippi School of Medicine, Jackson, 1963; in-
terned Duvac Medical Center, Jacksonville, Fla.,
one year; dermatology residency, University of
Arkansas Medical Center, Little Rock, July 17,
1966-July 16, 1969; elected Dec. 18, 1969 by
South Mississippi Medical Society.

Ederington, John Bayliss, Vicksburg. Born
Warren, Ark., Aug. 2, 1937; M.D., Tulane Uni-
versity School of Medicine, New Orleans, La.,
1963; interned Baptist Hospital, Nashville, Tenn.,
one year; ophthalmology residency Ochsner Foun-

dation, New Orleans, La., July 1, 1966-June 30,
1969; elected Jan. 13, 1970 by West Mississippi
Medical Society.

Fulcher, Luther Harrison, Jr., Jackson. Born
Jackson, Miss., Jan. 25, 1937; M.D., Tulane Uni-
versity School of Medicine, New Orleans, La.,
1963; interned Charity Hospital, New Orleans,
La., one year; medicine residency, same, July 1,
1964-June 30, 1967; elected Nov. 4, 1969 by
Central Medical Society.

Goodlow, William Henry, Jr., Jackson. Born
Siloam Springs, Ark., Jan. 31, 1936; M.D., Tu-
lane University School of Medicine, New Or-
leans, La., 1962; interned Confederate Memorial
Medical Center, Shreveport, La., one year; ob-
stetric and gynecology residency, City of Mem-
phis Hospitals, Memphis, Tenn., July 1, 1966-
June 30, 1969; elected Nov. 4, 1969 by Central
Medical Society.

Hickerson, Otrie Bertrelle, Jackson. Born
Coffeyville, Kan., Mar. 17, 1936; M.D., Howard
University College of Medicine, Washington,
D. C., 1962; interned Kings County Hospital,
Brooklyn, N. Y., one year; psychiatry residency,
Mental Health Institute, Independence, Iowa,
July 1, 1963-June 30, 1966; elected Nov. 4,
1969 by Central Medical Society.

April Course on
Physiology Set

The American College of Physicians and the
American Physiological Society will present a
seminar on current concepts in physiology of the
gastrointestinal, endocrine, and respiratory sys-
tems on April 9-11, 1970, at the Holiday Inn in
Philadelphia, Penn.

Director of the course is Dr. Daniel H. Sim-
mons, F.A.C.P. Fees for members and residents
and research fellows is $60.00. Fee for nonmem-
bers is $100.00.

The course is limited to no less than 50 regis-
trants and no more than 300.

All registration, requests for information, and
applications should be sent to: Dr. Edward C.
Rosenow, Jr., Executive Director, American Col-
lege of Physicians, 4200 Pine Street, Philadel-
phia, Penn. 19104.

MARCH 1970

125

ORGANIZATION / Continued

Simultaneous Vaccinations
Studied at MSBH

Field investigations and experience are show-
ing that for several live virus vaccine combina-
tions administered simultaneously at different in-
oculation sites, safety and immunologic response
are not significantly altered as compared to sin-
gle administration of these agents at monthly in-
tervals, reports the Mississippi State Board of
Health.

An example is the third dose of trivalent oral
poliovirus vaccine which is commonly given at
the time of smallpox vaccination during the sec-
ond year of life. In addition, DPT or Td toxoids
may be given with good effect at the same time.
Studies in progress indicate that it may be feasi-
ble, safe and efficacious to simultaneously ad-
minister such combinations as measles and small-
pox; mumps, measles and rubella; and measles,
mumps, smallpox and oral trivalent poliovirus
vaccines.

When considering the simultaneous adminis-
tration of 2 or more live virus vaccines each
combination must be individually assessed for
safety and efficacy as no general rule applying to
any and all combinations can be formulated from
our present data. Relatively new and recently li-
censed vaccines will be singly assessed for pos-
sible untoward reactions before combined use
with other agents is considered and studied.

AMA Establishes
Specialty Department

The American Medical Association established
a new headquarters staff department Jan. 22 to
strengthen liaison and services to related medi-
cal organizations. It is the Department of Spe-
cialty Society Services, reporting directly to Dr.
Richard S. Wilbur, assistant executive vice presi-
dent. Department Director is Theodore R. Chil-
coat, Jr., a five-year staff member formerly as-
signed to the AMA Washington Office.

The Department will serve and implement the
directives of the Interspecialty Committee which
was created in 1966. On the same date, Jan. 22,
Dr. Ernest B. Howard, AMA executive vice
president, announced that Dr. Wilbur was ap-
pointed secretary of the Committee, succeeding

Dr. Hugh H. Hussey, who was appointed direc-
tor of the AMA Division of Scientific Publica-
tions and editor of the Journal of the American
Medical Association Jan. 1.

Commenting on the new appointments, Dr.
Howard said, “The establishment of this special
department is an important step in strengthening
AMA’s relationship with the specialty societies,
and it is the culmination of a long range program
undertaken to upgrade the services of the AMA
to the specialty societies.

“After the founding of the Interspecialty Com-
mittee, the House of Delegates appointed an Ad
Hoc Committee to Study the Modus Operandi of
the Sections of the House of Delegates. Its report,
prepared under the direction of its chairman, Dr.
William F. Quinn, a Los Angeles surgeon, called
for the creation of a group of section councils to
provide specialty societies with direct representa-
tion in the AMA House of Delegates. The re-
port was adopted in July, 1969.

Its specific recommendations were to:

— “Establish a mechanism for stimulating in-
creased cooperation between the specialty medi-
cal societies and the AMA, thus forging a rela-
tionship that will bind specialty societies and the
AMA closer together, generating a singleness of
purpose which will benefit all of medicine;

— Give more satisfactory representation in
the House of Delegates to the specialty organiza-
tions;

— Provide for an increase in experience and
competent manpower to assist the Council on
Scientific Assembly in developing the Associa-
tion’s Annual Convention scientific program;

— Generate stimulating and engaging interdis-
ciplinary and specialty-oriented programs which
will command the interest of greater numbers of
practicing physicians;

— Provide a direct and continuing liaison be-
tween a section and its corresponding specialty
societies;

— Permit specialty societies direct access to the
House of Delegates through their appointed dele-
gates, and

— Give AMA specialty sections recognized
status by identifying them directly with the spe-
cialty societies.”

The Department’s responsibilities, under the
direction of Mr. Chilcoat and a staff aide, are to
assist Dr. Wilbur in his secretarial services to
the AMA Interspecialty Committee, further li-
aison with specialty groups, and advance the de-
velopment of the section councils of the House of
Delegates.

126

JOURNAL MSMA

Book Reviews

Essentials of Gastroenterology. By J. Ned
Smith, Jr., M.D., and Kyo R. Lee, M.D. St.
Louis: The C. V. Mosby Company, 1969.

This textbook is a concisely written one, cov-
ering practically every aspect of gastroenterology.
The text begins with the history and physical ex-
amination, and carries one through different
pathological entities of the gastro-intestinal tract.
Special interest is given to the radiological aspect
of gastro-intestinal pathology.

Chapter XIII, which deals primarily with the
liver, is a superbly written chapter that begins by
discussing the basic physiology of the liver and
continues through the management of different
hepatic diseases, such as hepatitis, cirrhosis,
bleeding varices, etc.

One of the splendid features of this book is
the excellent illustration of all the pathological
entities by well chosen x-ray films, which dem-
onstrate the discussed diseases.

This book would be of interest to all physi-
cians, regardless of specialty. I strongly recom-
mend that this book be made a part of every
physician’s library.

C. A. Marascalco, M.D.

Plastic and Maxillofacial Trauma Symposium.
Edited by Nicholas G. Georgiade. 221 pages and
390 illustrations. St. Louis: The C. V. Mosby
Company, 1969. $25.00.

The Educational Foundation of the American
Society of Plastic and Reconstructive Surgeons
holds regular, planned symposia for its mem-
bers, candidates, and friends in related special-
ties. This (Vol. I) is a condensed presentation
of the proceedings of the society held at Walter
Reed General Hospital on Nov. 30-Dec. 2, 1967.
It is regrettable that the slightest portion of any
presentation had to be deleted, but for the sake
of time and space and to avoid repetition, only
the “meat of the cocoanut” was published.

The editor, Nicholas G. Georgiade, D.D.S.,
M.D.. F.A.C.S., is professor of plastic and maxil-

lofacial surgery, Duke University Medical Center,
Durham, N. C. He is greatly interested in trau-
ma to the head and neck and is particularly
adept at organizing a book of this scope. Thirty
of America’s leading plastic and oral surgeons
and ophthalmologists have contributed short,
scholarly articles on problems thoroughly re-
searched and presented from first-hand knowl-
edge and experience. The papers are accurate as
to content and contain very few typographical
errors. Clarity of content was enhanced by dia-
grams and sketches in addition to the many rath-
er good black-and-white photographs.

The subject matter was divided into eight ma-
jor categories following the foreword written by
one of America’s oldest practicing plastic sur-
geons, Dr. Robert H. Ivy. Part I was moderated
by Dr. Clifford L. Kiehn of Western Reserve Uni-
versity. First-hand knowledge was given by plas-
tic surgeons on active duty in Vietnam as to med-
ical services, evaluation of missile wounds, man-
agement of military maxillofacial wounds and
care of civilian casualties of war.

Part II was moderated by Col. Wilfred T.
Tumbusch of Walter Reed Hospital, Washington,
D. C., dealing with general considerations of the
problem of maxillofacial trauma. This included
resuscitation following maxillofacial trauma, cas-
ualty examination and triage and anesthesia for
the combat casualty.

Parts III through VII were presentations of
the mandible, maxilla, nose, zygoma, and soft
tissue repair. Each section was expertly handled
with an introduction of the problems involved and
a review of the anatomy and physiology close-
ly involved. At the end of each major section
was presented a question and answer round ta-
ble. This was apropos in giving everyone a chance
to present his own particular problem from back
home for consideration of the experts. Part VIII
presented trauma problems of special considera-
tion. In it were included particular experiences
of the author in treating facial fractures in chil-
dren, late complications of facial injuries and in-
juries to the facial nerve, trauma to the laryngo-
trachea, and immediate mandibular repair in
“blow-out” jaw injuries.

MARCH 1970

127

LITERATURE / Continued

This book should make a decided addition to
the library of anyone treating trauma, be it acute,
delayed, or of such severity that complicated
staged procedures will have to be done. Many
general surgeons and general practitioners far re-
moved from medical centers are required, not
by choice, to treat a certain amount of facial
trauma. Parts I, II, and VIII would give these
men added self confidence. Further points of
technique may be gleaned from the remaining
chapters and also help to establish one’s psy-
chology of management, i.e. what, when, and to
whom shall I send the cases beyond my field of
competence.

I found this book rewarding and worth the
time and effort of reading. I hope that the Edu-
cational Foundation will see fit to continue pub-
lishing each of its trauma symposia. And to quote
Dr. Robert H. Ivy, “I hope it will fulfill the pri-
mary educational purpose intended, serve to add
definition to the respective fields of endeavor of
the specialties, and involve and foster coopera-
tive efforts of care in the best interests of the pa-
tient.”

Martin B. Harthcock, M.D.

Sheen Award
Deadline Announced

The American Medical Association has an-
nounced that the closing date for receiving nomi-
nations of physician-candidates for the Dr. Rod-
man E. Sheen and Thomas G. Sheen Award is
March 15. Nominations received by this date will
be examined by a committee of physicians named
by the AMA Board of Trustees.

Candidates must be American citizens pos-
sessing an M.D. degree who have made out-
standing contributions to medicine; however,
these contributions need not have been made in
only the year preceding the nomination, nor
need these activities have been conducted with-
in the United States. The award can recognize
either a single achievement in medicine or an ac-
cumulated career of excellence.

Nominations for the annual $10,000 award
will be accepted from state and local medical so-
cieties, medical specialty societies, medical re-
search organizations, medical schools, hospital
medical staffs, public health agencies at all levels
of government, and other appropriate military or
civilian agencies.

The award was established under a bequest
in the will of Thomas G. Sheen, an Atlantic
City, N. J., businessman, as a memorial to his
brother, Dr. Rodman E. Sheen, whose career was
cut short by a Roentgen tube explosion. The
trustee of the estate and dispenser of the award
funds is the Guarantee Bank and Trust Com-
pany of Atlantic City, which invited the AMA to
establish and conduct procedures for selecting
and presenting the award.

Announcement and presentation will be made
June 21 in Chicago during the AMA Annual
Convention.

Previous recipients are Drs. Irvine H. Page,
Cleveland, O., and Robert E. Gross, Boston,
Mass.

The nominations, in writing, should be ad-
dressed to The Sheen Award Committee, AMA,
535 North Dearborn Street, Chicago, 111. 60610.

Pre -Addressed Labels
Speed Tax Refunds

Income tax refunds can be processed quicker
if taxpayers put the pre-addressed name label
that came on their 1040 tax package onto the
return they file, J. G. Martin, Jr., District Di-
rector of Internal Revenue for Mississippi, said
today.

Use of the name label will eliminate many er-
rors in name and Social Security numbers that
held up refunds last year.

Returns filed before April 1 using the name
label can usually be processed and the refund is-
sued in five to six weeks. Taxpayers who find an
error in their name label should correct the label
and use it on their return.

When a return is prepared by someone else,
the taxpayer should remember to put the name
label on the form he actually files. Taxpayers
should either give the tax preparer the form
with the name label attached, or attach the name
label themselves when the completed form is re-
turned to them for signing.

The name label is sometimes called the piggy-
back label because a carbon copy of the informa-
tion appears beneath the label. If you do not
file the return mailed you, the top label can thus
be lifted off and put on the return you do file.

Martin said taxpayers required to file estimated
tax declarations should use the pre-addressed
form sent them by IRS.

128

JOURNAL MSMA

thing

relief for
ir-raising
cough

|BlM§p

EXPECTORANT

Each fluidounce contains: 80 mg. Benadryl ®
hydrochloride), Parke-Davis; 12 grains ammonium chloride;
sodium citrate; 2 grains chloroform; 2 / 10 grain menthol; and
An antitussive and expectorant for control of coughs due to colds
of allergic origin, BENYLIN EXPECTORANT is the leading cough
ration of its kind. BENYLIN EXPECTORANT tends to inhibit cough
...soothes irritated throat membranes. And its not
raspberry flavor makes BENYLIN EXPECTORANT easy to
PRECAUTIONS: Persons who have become drowsy on this or other
antihistamine-containing drugs, or whose tolerance is not known,
should not drive vehicles or engage in other activities requiring keen
response while using this preparation. Hypnotics, sedatives, or tran-
quilizers if used with BENYLIN EXPECTORANT should be prescribed
with caution because of possible additive effect. Diphenhydramine
has an atropine-like action which should be considered when pre-
scribing BENYLIN EXPECTORANT.

ADVERSE REACTIONS: Side reactions may affect the nervous, gastro-
intestinal, and cardiovascular systems. Drowsiness, dizziness, drynesi
of the mouth, nausea, nervousness, palpitation, and blurring of
vision have been reported. Allergic reactions may occur.

PACKAGING: Bottles of 4 oz., 16 oz., and 1 gal.

Parke, Davis & Company, Detroit, Michigan 48232

PARKE-DAVIS

SOSS9

His heart tells him he’s an invalid.
You know he’s not.

Contraindications: History of sensitivity to meprobamate.

Important Precautions: Carefully supervise dose and
amounts prescribed, especially for patients prone to
overdose themselves. Excessive prolonged use has been
reported to result in dependence or habituation in suscep-
tible persons, as alcoholics, ex-addicts, and other severe
psychoneurotics. After prolonged excessive dosage,
reduce dosage gradually to avoid possibly severe withdrawal
reactions. Abrupt discontinuance of excessive doses has
sometimes resulted in epileptiform seizures.

Warn patients of possible reduced alcohol tolerance, with
resultant slowing of reaction time and impairment of
judgment and coordination.

Reduce dose if drowsiness, ataxia or visual disturbance
occurs; if persistent, patients should not operate vehicles
or dangerous machinery.

Side Effects include drowsiness, usually transient; if
persistent and associated with ataxia, usually responds to
dose reduction; occasionally concomitant CNS stimulants
(amphetamine, mephentermine sulfate) are desirable.
Allergic or idiosyncratic reactions are rare, but such
reactions, sometimes severe, can develop in patients
receiving only 1 to 4 doses who have had no previous
contact with meprobamate. Previous history of allergy may
or may not be related to incidence of reactions. Mild
reactions are characterized by itchy urticarial or
erythematous maculopapular rash, generalized or confined
to groin. Acute nonthrombocytopenic purpura with
cutaneous petechiae, ecchymoses, peripheral edema and
fever have been reported. One fatal case of bullous
dermatitis following intermittent use of meprobamate with
prednisolone has been reported. If allergic reaction
occurs, meprobamate should be stopped and not
reinstituted. Severe reactions, observed very rarely, include
angioneurotic edema, bronchial spasms, fever, fainting
spells, hypotensive crises (1 fatal case), anaphylaxis,

iety is expected in the cardiovascular patient,
tie may even be desirable.

when anxiety is exaggerated . . . when it
rferes with sleep . . . when it aggravates
liovascular symptoms, your help may
leeded.

jrally, you’ll want to reassure the patient.

perhaps prescribe Equanil (meprobamate)
djunctive therapy. It helps relieve anxiety
tension specifically, yet gently.

ost 15 years’ use has shown that Equanil
sually well tolerated as well as effective.

5 effects are generally limited to transient
vsiness; serious, therapy-interrupting
effects are rare.

stomatitis and proctitis (1 case) and hyperthermia. Treat
symptomatically as with epinephrine, antihistamine and
possibly hydrocortisone. Aplastic anemia (1 fatal case),
thrombocytopenic purpura, agranulocytosis and hemolytic
anemia have occurred rarely, almost always in presence of
known toxic agents. A few cases of leukopenia usually
transient, have been reported on continuous administration.
Meprobamate may sometimes precipitate grand mat '
attacks in patients susceptible to both grand and petit mal.
Extremely large doses can produce rhythmic fast activity
in the cortical pattern. Impairment of accommodation and
visual acuity has been reported rarely. After excessive
dosage for weeks or months, withdraw gradually (1 or 2
weeks) to avoid recurrence of pretreatment symptoms
(insomnia, severe anxiety, anorexia). Abrupt discontinuance
of excessive doses has sometimes resulted in vomiting,
ataxia, tremors, muscle twitching and epileptiform
seizures. Prescribe very cautiously and in small amounts
for patients with suicidal tendencies. Suicidal attempts
have resulted in coma, shock, vasomotor and respiratory
collapse and anuria. Excessive doses have resulted in
prompt sleep; reduction of blood pressure, pulse and
respiratory rates to basal levels; and occasionally
hyperventilation. Treat with immediate gastric lavage and
appropriate symptomatic therapy. (CNS stimulants and
pressor amines as indicated.) Doses above 2400 mg. /day
are not recommended.

Composition: Tablets, 200 mg. and 400 mg. meprobamate.
Coated Tablets, WYSEALS® EQUANIL (meprobamate)

400 mg. (All tablets also available in REDIPAK® [strip
pack], Wyeth.) Continuous-Release Capsules,

EQUANIL L-A (meprobamate) 400 mg.

Wyeth Laboratories Philadelphia, Pa.

Equanil’

(meprobamate)

Man in space, now fait accompli, re-emphasizes the
importance of Uro-Phosphate therapy. Research into
the effect of space travel on the astronaut reveals
that weightlessness causes loss of bone calcium. As
the bones are required to bear less and less of the
weight of the body they lose calcium, increasing the
calcium content of the urine. When physical activity
is reduced, the acidity of the urine should be adjusted
to keep increased calcium in solution .... a prophy-
laxis to prevent kidney or bladder calculi.

Uro-Phosphate.

NOW A SUGAR-COATED TABLET

Each tablet contains: methenamine, 300 mg.; sodium acid phosphate, 500 mg.

Uro-Phosphate gives comfort and protec-
tion when inactivity causes discomfort in
the urinary function. It keeps calcium in
solution, preventing calculi; it maintains
clear, acid, sterile urine; it encourages

Dosage:

For protection of the inactive patient

1 or 2 tablets every 4 to 6 hours is
usually sufficient to keep the urine
clear, acid and sterile.

2 tablets on retiring will keep residual
urine acid and sterile, contributing to
comfort and rest.

A clinical supply will be sent to
physicians and hospitals on request.

complete voiding and lessens frequency
when residual urine is present.

Uro-Phosphate contains sodium acid
phosphate, a natural urinary acidifier.
This component is fortified with methe-
namine which is inert until it reaches the
acid urinary bladder. In this environment
it releases a mild antiseptic keeping the
urine sterile.

Uro-Phosphate is safe for continuous use.
There are no contra-indications other
than acidosis. It can be given in sufficient
amount to keep the urine clear, acid and
sterile. A heavy sugar coating protects its
potency.

WILLIAM P. POYTHRESS & COMPANY, INC., RICHMOND, VIRGINIA 23217

MEDICAL ORGANIZATION

Annual Session Is Set for May 11-14;
Scientific Work, Fun, Elections on Agenda

The association’s 102nd Annual Session may
be the biggest thing to hit the Gulf Coast since
Hurricane Camille — but with exactly the oppo-
site effect. The May 11-14 scientific, social, busi-
ness, and fellowship gala will be headquartered
at the Buena Vista Hotel and Motel at Biloxi.

Drs. James L. Royals, president, and Walter H.
Simmons, chairman of the Council on Scientific
Assembly, said that the House of Delegates will
meet on Monday, May 11, with the Scientific
Assembly opening on the following day.

The Woman’s Auxiliary has scheduled its 47th
Annual Session May 11-13, also at the Buena
Vista, according to Mrs. Louis C. Lehmann of
Natchez, state president.

Concurrent meetings include more than 12
specialty groups and four medical alumni orga-

nizations. Technical and scientific exhibits will
be presented in the headquarters hotel.

Meeting in general sessions, the Scientific As-
sembly opens on Tuesday morning with surgery,
and obstetrics and gynecology is set for the after-
noon. A joint session Wednesday morning fea-
tures general practice and preventive medicine,
while internal medicine occupies the afternoon
program.

The final day is divided between scientific
work and business with eye, ear, nose, and
throat and the pediatrics programs running con-
currently in the morning. The adjourned meeting
of the House of Delegates is set for the after-
noon.

Medical alumni occasions kick off with Ole
Miss on Monday evening. Tennessee, Tulane, and

THE BUENA VISTA HOUSING PICTURE

Although heavily hit by killer Camille, the
Buena Vista was one of the few Coast busi-
nesses and institutions which never lost a
day following the hurricane. The original
motel complex around the pool was de-
stroyed, but the new and modern high-rise
unit was virtually undamaged.

The main hotel, modernized and refur-
bished during the past two years, sustained
damage only at ground level where the
coffee shop, Marine Room, and WLOX-TV
studios were located.

A crash rebuilding program in the orig-
inal motel complex is underway, and some
units may be available for the 102nd An-

nual Session. The association will, however,
be able to anticipate a shortage of 75 to
100 rooms.

To offset this headquarters hotel room
shortage, representatives of exhibiting or-
ganizations will be assigned housing at the
White House, and first priority for Buena
Vista rooms will be reserved for members
and families. Nearby modern, air condi-
tioned rooms are available for overflow.

The association advises all who plan to
attend the annual session to secure reserva-
tions at the earliest moment to assure con-
firmation in the hotel of personal choice.

MARCH 1970

129

ORGANIZATION / Continued

Vanderbilt are set for Tuesday, and the associa-
tion party and dance is on the ticket for Wednes-
day.

Twenty-five vacancies in elected offices will
be filled on May 14 at the final meeting of the
House. The long ballot will be announced by
the Nominating Committee on May 1 3, accord-
ing to Dr. William E. Lotterhos of Jackson,
speaker of the House, and John B. Howell, Jr.,
of Canton, vice speaker.

Dr. Paul B. Brumby of Lexington will be in-
augurated president for 1970-71 during closing
ceremonies.

The Board of Trustees will meet daily during
the annual session, said Dr. Mai S. Riddell, Jr.,
of Winona, Board chairman. Serving with him in
leadership positions this year are Drs. J. T. Da-
vis of Corinth, vice chairman, and William O.
Barnett of Jackson, secretary.

Offices to be filled by the delegates on May 1 4
are:

President-elect

Nominate three, no two of whom may be from
the same county, elect one.

Vice Presidents

Nominate three for the Northern Area, three
for the Mid-State Area, and three for the South-
ern Area. Elect one for each area.

Secretary-T reasurer

Term 1970-73. Nominate three, elect one. In-
cumbent: Walter H. Simmons, Jackson.

Speaker of the House of Delegates

Term 1970-73. Nominate three, elect one. In-
cumbent: William E. Lotterhos, Jackson.

Vice Speaker of the House of Delegates

Term 1970-73. Nominate three, elect one. In-
cumbent: John B. Howell, Jr., Canton.

Associate Editor

Term 1970-72. Nominate two, elect one. In-
cumbent: George H. Martin, Vicksburg.

Delegate to AM A

Term Jan. 1, 1971-Dec. 31, 1972. Nominate
two, elect one. Incumbent: Howard A. Nelson,
Greenwood.

Alternate Delegate to AM A

Term Jan. 1, 1971-Dec. 31, 1972. Nominate
two, elect one. Incumbent: Stanley A. Hill, Cor-
inth.

Board of Trustees, Dictricts 1,2, and 3

Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents:
John M. Alford, Greenwood, District 1; James
O. Gilmore, Oxford, District 2; and J. T. Davis,
Corinth, District 3.

Council on Budget and Finance

Term 1970-73. Nominate two, elect one. In-
cumbent: Daniel L. Hollis, Biloxi.

i

Council on Constitution and By-Laws

Term 1970-73. Nominate two, elect one. In-
cumbent: Arthur E. Brown, Columbus.

Judicial Council, Districts 7 , 8, and 9

Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents:

J. P. Culpepper, Jr., Hattiesburg, District 7; Leo
J. Scanlon, Jr., Natchez, District 8; and James T.
Thompson, Moss Point. District 9.

Council on Legislation, Districts 4 , 5, and 6
Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents:
Paul B. Brumby, Lexington, District 4; George
E. Twente, Jackson, District 5; and Guy T. Vise,
Meridian, District 6.

Council on Medical Education

Term 1970-73. Nominate two, elect one. In-
cumbent: Frederick E. Tatum, Hattiesburg.

Council on Medical Service, Districts 7 , 8, and 9
Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents:
Charles R. Jenkins, Laurel, District 7; Jack A. At-
kinson, Brookhaven, District 8; and Bedford F.
Floyd, Gulfport, District 9.

Mississippi State Board of Health

No vacancies will occur in 1970 among phy-
sician-members.

ICS Schedules 17th
Congress in Paris

The International College of Surgeons will
hold its 17th World Congress in Paris at the Mai-
son de la Chimie on April 19-25, 1970.

The clinical meetings will feature presenta-
tions on cardiac surgery, gynecology, orthopae-
dics, thoracic surgery, ENT, ophthalmology, radi-
ology, urology, oncology, gastro-intestinal sur-
gery, and other specialized areas.

Clinical conferences throughout the week will
be held at the different hospitals in Paris.

For further information write: Expositions et
Congre’s 22, rue Royale. Paris (France).

130

JOURNAL MSMA

Technicon Announces
AutoAnalyzer II

Technicon Corporation, producers of the
world’s first automated system for wet chemical
analysis, has announced AutoAnalyzer® II,
the second generation of the AutoAnalyzer fam-
ily. “In 1957, Technicon introduced the Auto-
Analyzer and established a new standard for
chemical analysis,” commented Edwin C. White-
head, president of Technicon. “We have every
confidence that the impact of AutoAnalyzer II
will be as great.”

The basic AutoAnalyzer was quickly adopted
by hospital laboratories, already feeling the pres-
sures of increasing workloads and diminished
staff. Research and industrial labs followed suit,
and soon laboratories throughout the world were
not only depending upon the AutoAnalyzer, but
were also developing new methodologies for ap-
plying it to their special analytical problems.

Now, the years of experience with AutoAna-
lyzer systems, the advanced technology that pro-
duced Technicon Sequential Multiple Analysis
(SMA)® systems, and the increasingly sophisti-

cated demands of AutoAnalyzer users have come
to fruition with the development of AutoAnalyz-
er II, a new species of basic analytical system.
AutoAnalyzer II combines the many virtues of
the first generation instrument with innovative
features of the SMA systems to offer a compact,
fast, accurate, and flexible instrument for use in
medicine, research, and industry.

Whitehead explained that an important ad-
vance in AutoAnalyzer II is its capacity to
achieve, and record results at, “steady state,” a
condition of equilibrium in the flowcell in which
all effects of possible sample interaction have
been eliminated and the recorded signal is a true
reflection of the constituent being measured. Other
advantages described by Whitehead are the new
digital printer incorporated in AutoAnalyzer II,
which makes the instrument compatible with
any hospital computer system (giving physicians
immediate access to results in conjunction with
other vital patient information stored in the com-
puter); increased rates of analysis (in some cases
doubling previously achievable speeds); single
point calibration (minimizing operator effort and
also increasing the total number of samples run
per hour by reducing the number of standards

Technician is shown with Technicon s new AutoAnalyzer II, a new species of basic analytical system.

MARCH 1970

131

ORGANIZATION / Continued

per tray); and flexibility (interchangeable “car-
tridges” are available for each chemical analy-
sis).

“We anticipate an immediate response from
clinical laboratories,” Whitehead said, “where
there is a critical need for rapid and accurate
analysis of blood and other physiologic fluids.”
Through the simple substitution of analytical car-
tridges, complete with a unique “timed” reagent
pack specific to each analysis, a variety of pro-
cedures may be performed.

With AutoAnalyzer II as many as three ana-
lytical procedures may be run simultaneously,
providing multi-test capability. This is a very
significant feature for small labs, because it in-
creases their total analytical capability with a
minimum of expense. In large labs where SMA
systems are already in use, AutoAnalyzer II en-
ables users to dedicate from one to three analyt-
ical channels to those tests that must be run
repetitively. The small sample size required for
analysis in AutoAnalyzer II is important in the
clinical lab. particularly in the case of pediatric or
geriatric patients, or the critically ill.

“While the adoption by research and indus-
trial labs may take a little longer, we know that
the versatility, accuracy and speed of AutoAna-
lyzer II, combined with its capacity for continu-
ous, unattended operation, will prove very at-
tractive to them. We are proud of AutoAnalyzer
II for many reasons,” Whitehead continued, “one
of the most important being that it demonstrates
Technicon’s continuing dedication to the develop-
ment of the world’s finest instruments for auto-
mated chemical analyses.”

Alabama Names New
Psychiatry Chief

Dr. Patrick H. Linton has been named pro-
fessor and chairman of the department of psy-
chiatry, University of Alabama School of Medi-
cine.

The announcement was made by the dean of
the School of Medicine, Dr. Clifton K. Meador,
who said that Dr. Linton’s appointment is ef-
fective immediately.

Dr. Linton has served as acting chairman of
the department since Aug. 1968, following the
resignation of Dr. James Sussex.

Dean Meador said “Dr. Linton has been most

effective as acting chairman for the past 15
months; we are pleased to have him confirmed
as chairman. Psychiatry has emerged as one of
the leading disciplines of the School of Medicine.
It is anticipated that the department, under his
skilled leadership, will be greatly enlarged and
strengthened in the months to come.”

Prior to joining the UAB faculty in 1961, Dr.
Linton served as staff psychiatrist with Veterans
Administration Hospitals in New Orleans, Tope-
ka and Fort Lyon, Colo. He was acting chief of
the Psychiatric Service at the Birmingham VA
Hospital from 1962 till 1968.

A graduate of Birmingham-Southern College
(1949), Dr. Linton received his M.D. degree
from the Medical College of Alabama (1953),
served his internship at the U.S. Naval Hospital
in Jacksonville, Fla. (1953-54), and his resi-
dency in psychiatry at the Menninger School of
Psychiatry, Topeka (1954-56, 1958-59).

A native of Lineville, Ala., Dr. Linton also
holds the appointment of associate professor of
dentistry. University of Alabama School of Den-
tistry.

Alabama Medicaid OKs
Mississippi M.D.’s

Physicians located along the eastern border
of the state may participate in not one but two
Medicaid programs. Through an arrangement
between the Mississippi State Medical Associa-
tion and the Alabama Medical Services Admin-
istration, border county physicians are eligible
to care for Alabama Medicaid patients.

Sam T. Hardin, Jr., of Montgomery, staff ad-
ministrator in the Alabama Medicaid office, has
informed the association that a single letter from
a Mississippi physician can complete the ar-
rangement.

Mississippi M.D.’s interested in qualifying for
Alabama Medicaid participation should write
Alabama Blue Cross, 930 S. 20th St., Birming-
ham 35205, requesting assignment of an Ala-
bama Medicaid registry number. Applicants
should give their full names, professional ad-
dress, city and ZIP code and their permanent
Mississippi medical license number. Claim forms
may be secured from this agency.

The opportunity is open to any licentiate in
the state but will be particularly applicable to
easternmost members of the Northeast Missis-
sippi, Prairie, East Mississippi, South Mississippi,
and Singing River medical societies.

132

JOURNAL MSM A

Cancer Quiz

Cancer Committee
University Medical Center
Jackson, Mississippi

This feature, consisting of review questions re-
lated to the cancer field, was prepared by Dr.
Myron Lockey of Jackson, member of the Cancer
Committee, University Medical Center. Answers
appear on a separate page.

Questions from readers related to these review
questions may be submitted to the Editors of the
Journal for forwarding to the committee. Each
will receive a personal reply. Suitable questions
from readers will be considered for publication.
This second presentation relates to laryngeal can-
cer.

Comment and suggestions are invited from
readers. — The Editors.

1. The disease predominantly affects males in
the ratio of:

A. 2:1

B. 3:1

C. 4:1

D. 8:1

2. The most common variety of tumor is:

A. Adenocarcinoma

B. Squamous Carcinoma

C. Sarcoma

3. Carcinoma of the vocal cord is characterized
by early metastasis to the neck.

True

False

4. Persistent ear pain without ear pathology
may represent carcinoma of the larynx.

True

False

5. The clinical staging of carcinoma of the
larynx helps very little in the clinical man-
agement of such cases.

True

False

6. The most frequent presenting complaint in
carcinoma of the larynx is throat pain.

True

False

7. A patient with hoarseness and a neck node
requires biopsy of the neck node.

True

False

8. The treatment of choice for lesions limited
to a vocal cord without loss of cord mobility
is:

A. Surgery

B. Radiation

C. Chemotherapy

9. In large lesions of the larynx preoperative
radiation therapy followed by immediate sur-
gery is better than either modality alone.

True

False

10. X-Ray tomography of the larynx is very
helpful in evaluating extent of lesions in-
volving the larynx.

True

False

( Answers on page 146 )

MARCH 1970

133

ORGANIZATION / Continued

Arts Festival Involves
Many Physicians' Wives

Key positions in the Mississippi Arts Festival
April 13-19 will be filled by wives of physicians,
dentists and others in the medical community of
Jackson.

The mammoth cultural presentation — seven
days in spring — features national and statewide
talent in art, music, drama, dance, and litera-
ture. “American Heritage” is the theme of the
1970 production. Centered at the fairgrounds in
Jackson, it is sponsored this year for the first
time by Mississippi Arts Festival, Inc.

The present five-person executive or produc-
tion committee was appointed by the Junior
League of Jackson, which, with the Civic Arts
Council, had sponsored the festival for six years.
This is the first festival under sponsorship of the
incorporated group.

On the five-person executive committee, of
which Mrs. Randolph Peets, Jr., is chairman and
Mrs. William L. Crim co-chairman, are three
persons identified with the medical community.

Mrs. Albert Meena, whose husband is a Jack-

More than 100 wives of physicians, dentists, and
related medical service leaders in Jackson will work
in key positions for Mississippi Arts Festival April
13-19. Mrs. Randolph Peets, Jr., second from left,
is chairman, and Mrs. William Crim , third from left
is co-chairman. Mrs. Albert Meena, right, wife of
a Jackson surgeon, is secretary; Mrs. Chandler
Clover, left, wife of the administrator of Doctors
Hospital, is promotion chairman; and Mrs. David
McNamara, second from right, wife of a sales rep-
resentative for McNees Surgical Supply Company,
is treasurer.

1 3 4

son surgeon, is secretary; Mrs. Chandler Clov-
er, whose husband is administrator of Doctors
Hospital, is promotion chairman; and Mrs. David
McNamara, whose husband is sales representa-
tive for McNees Medical Supply Company, is
treasurer.

Medical wives filling chairman and co-chair-
man positions on committees are: Mrs. John T.
Kitchings, artists arrangements; Mrs. William S.
Cook, Flag Pageant; Mrs. James R. Cavett, Jr.,
mimeograph; Mrs. Clarence Webb, Jr., home-
making seminar; Mrs. Thomas Turner, home-
making seminar; Mrs. A. V. St. Clair, informa-
tion booth, American Association of University
Women; Mrs. J. O. Manning, arts and crafts ex-
hibition; Mrs. Chester Lake, program;

Mrs. W. C. Shands, youth concerts; Mrs.
J. Manning Hudson, youth concerts; Mrs. Henry
Webb, mailing; Mrs. Howard Cheek, parking;
Mrs. H. M. Fairchild, South Jackson Civic
League workshop; Mrs. James D. Hardy, pro-
gram distribution;

Mrs. Heber Simmons, Old Capitol exhibit;
Mrs. Sam Sanders, lighting and hostesses in
youth pavilion; Mrs. Noel Toler, fairgrounds;
Mrs. Jack Fowler, high school art; Mrs. Palmer
Wilks, youth pavilion workshop.

Other involved physicians’ wives include Mrs.
Jim Hayes, Mrs. Elmer Nix, Mrs. Roland Sam-
son, Mrs. Thomas Kilgore, Mrs. Julian Hender-
son, Mrs. Alvin Brent, and Mrs. T. E. Wilson,
III.

Tickets will be available after March 2 for $5,
$10, and $15. They will admit the holder to
two evening programs in the Coliseum and one
in the city auditorium, all featuring nationally
known stars, and to all other activities, including
exhibits, art shows, concerts, opera, ballet, chil-
dren’s plays and puppet shows, and the spec-
tacular Flag Pageant by the Pensacola Naval Air
Training Station.

Exhibits will be housed in two large buildings.
The first will present the Mississippi Art Asso-
ciation’s national competition, “Images on Pa-
per”; the high school art contest; and the Festi-
val’s sixth annual Arts and Crafts Show. Signifi-
cant prizes will be awarded in these contests.

The second building will trace “American
Heritage” by recreating interiors of shops and
homes through five eras: Colonial, Ante-Bellum,
Victorian, War Years, and Modern Day. Antiques
will contribute to the authenticity of the older
decors.

Winners of the statewide children’s art com-
petition will be displayed in a town square in
the center of the American Heritage Building.

JOURNAL MSMA

The Youth Pavilion (formerly children’s divi-
sion) will depict 48 scenes from the nation’s
birth through space exploration. The scenes will
be grouped under the headings “A New Nation
Is Born,” “A New Nation Emerges,” “We Develop
Culturally,” “War Between the States,” “Our Na-
tion Reunited,” and “This Fabulous Century.”

The Jackson Symphony Orchestra, under the
direction of Lewis Dalvit, will not only partici-
pate in the evening Coliseum programs but will
offer four other concerts during the week. Three
of these will be for local and out-of-town sixth
grade pupils. The other will be a Saturday morn-
ing presentation in the Coliseum for all ticket
holders.

Classical musicians from throughout Missis-
sippi will be featured at “The Met,” with stu-
dent artists at “The Mini-Met.” Popular talent
will be heard in the coffee house.

Personnel from the Pensacola Naval Air Sta-
tion will present their exciting Flag Pageant, a
30-minute program including band music, nar-
ration, costumes, and uniforms of the various
armed services in American history.

The University of Mississippi will present the
opera “Don Giovanni,” and the University of
Southern Mississippi will give a children’s opera,
“L’Enfant et Les Sortileges” by Ravel.

There will be homemaking seminars in cre-
ative stitchery and gourmet cooking.

Nearly 1,000 original manuscripts have been
submitted to the literary competition since its be-
ginning in 1967. There are five categories in the
senior division for adults and college students:
drama, short story, formal essay, informal es-
say, and poetry. The junior division for high
school students includes short story, informal es-
say, and poetry. Awards of $100 for senior first
places and $25 for juniors will be made at a
literary seminar.

Judges for the literary competition will be
Willie Morris, editor of Harpers magazine and
author of North Toward Home, senior formal
essay judge; Berry Reese, senior editor for
Houghton-Mifflin Publishing Company, senior in-
formal essay; James T. Whitehead, noted poet
and faculty member of the University of Arkan-
sas, senior poetry; Dr. Margaret Walker Alex-
ander, author of the novel Jubilee and faculty
member at Jackson State College, senior short
story; Michael Dendy, staff and faculty member
of the Dallas Theater Center, senior drama; Dr.
William Durrett, Belhaven College, junior infor-
mal essay; Barry Hannah, Clemson University,
junior short story; and Mrs. Lois Taylor Black-
well, Millsaps College, junior poetry.

More Medicare, Medicaid
Regulations Announced

New regulations to make sure that Medicare
and Medicaid do not recognize inflated values
of profit-making health facilities in paying costs
of medical care for the aged were announced by
Robert M. Ball, Commissioner of Social Security.

“This is part of the continuing effort to elimi-
nate all possible fiscal loopholes — potential as
well as existing — in the operation of these prob-
lems,” Commissioner Ball said.

The regulations announced deal with both the
valuation of depreciable assets and the rate of
depreciation the federal government will recog-
nize in reimbursing proprietors for the costs of
health care under Medicare and Medicaid.

One change would require that the owner
value his depreciable properties at the lowest of
three figures: actual cost, fair market value or
replacement cost adjusted for depreciation.

The other would forbid the use of accelerated
depreciation in the case of all new operators —
and of new assets brought into the Medicare
program by existing providers of services.

There have not, as yet, been major abuses in
these areas, Mr. Ball emphasized. “Although we
have made every effort under present regula-
tions to insure that valuations of depreciable as-
sets on fair market value are just that — not the
result of a sale at an inflated price.” Commissioner
Ball said, “the changes will enable us to impose
even firmer controls.”

Under existing regulations, the operator is al-
lowed to calculate his depreciation at acceler-
ated rates. That is, he can charge off higher costs
in the early years and lower ones in the later.
Over the long run these balance out and the cost
to the government in reimbursement is not great-
er. But if a facility using accelerated deprecia-
tion is sold in the early years, the government
can require an adjustment in the higher costs it
has paid for this period.

Nevertheless, increasing and widespread spec-
ulative activity in these properties poses a future
threat that overall fair market value may become
inflated. Using actual replacement cost (less de-
preciation) as a ceiling on valuation should in-
sure that this threat does not materialize and ad-
versely affect government reimbursement, Com-
missioner Ball emphasized. He gave this hypo-
thetical illustration of the situation the new regu-
lations are designed to prevent.

A nursing home operator has $700,000 in-
vested in buildings and equipment and another

MARCH 1970

135

ORGANIZATION / Continued

$50,000 in land. On the $700,000 of depreci-
able property, he is now allowed to take acceler-
ated depreciation and include this in his costs.
Fifteen per cent of his beds are occupied by
Medicare patients. A corresponding share of his
depreciation is allowed in the base for the cost
settlement Medicare makes with him at the end
of the year.

Should he sell the buildings, equipment and
land after 2 years for $1,000,000, the revised
regulations would prevent the new owner from
automatically valuing his facility at this amount
and thus qualifying for a higher cost base on
which to calculate his depreciation. Instead, he
would be required to use the lower figure of re-
placement cost less depreciation.

Assuming, in this case, that the replacement
cost of the depreciable assets (but not the land)
has risen in the 2-year period by 12 per cent,
the new owner’s cost basis for purposes of de-
preciation would come to $784,000, less two
years straight-line depreciation, based on a 40-
year life, of $39,200. This would amount to
$734,800 rather than the $950,000 he paid
(apart from land). With respect to the propor-
tion of the extended care facility devoted to
Medicare patients this would mean a difference
in cost basis of $32,280, or some $807 a year on
a 40-year depreciation schedule.

The new regulations would also tighten re-
covery provisions significantly in the case of
capital gain on the sale of a facility. The Social
Security Administration would be required to re-
cover the difference between the amount allowed
under accelerated depreciation and what this
would have been on a straight-line basis.

The regulations would also extend present
provisions governing gains or loses on sales of
depreciable assets to apply to sales that occur
within a year after the original proprietor ceased
to participate in the Medicare program.

In addition the proposed changes would
tighten the rules relating to return on equity. Un-
der the law, the provider is paid a rate of return
(currently about 9 per cent) on his equity — the
amount of his own, as opposed to borrowed,
money invested — in the proportion that the fa-
cilities are used for Medicare basis. This, too, is
limited by a fair value base. By using replacement
cost (if this is lower) rather than fair market
value, the threat of overall market value inflation
is eliminated.

The proposed new rules are expected to be

published in the Federal Register in the near fu-
ture. Interested parties will have 30 days to sub-
mit data, comments and arguments before the
regulations are made final.

Dr. McCaskill Acquitted
of Abortion Murder

A Coahoma County Circuit Court jury has
acquitted Dr. Luther W. McCaskill of Clarksdale
of murder in the 1967 abortion death of Mrs.
Emma Flowers Hurt of Greenwood.

Dr. McCaskill pleaded not guilty and testified
that Mrs. Hurt told him she received an abortion
from a Greenwood doctor before he saw her.

The physician was convicted on the charge in
August 1968, but the state Supreme Court or-
dered a new trial because of improper jury in-
struction.

Dr. McCaskill now faces trial in the abortion
death of another woman and abortion charges
in the cases of two others, according to press re-
ports. He has been serving a sentence in the
Mississippi Penitentiary at Parchman on abor-
tion conviction.

St. Dominic Elects
Medical Staff

A new Medical Staff has been elected at St.
Dominic-Jackson Memorial Hospital. Dr. Rob-
ert E. Tyson is Incoming Chief of Staff and Dr.
Rush E. Netterville is Past Chief.

Secretary is Dr. Thomas E. Stevens and Dr.
William B. Thompson is Chief Elect. Dr. Tyson
and his officers will serve for two years instead
of one year as has been customary.

Section Chiefs, who with the Secretaries, will
each serve three years, have been named as fol-
lows: Dr. Hardy B. Woodbridge (general prac-
tice) with Dr. Charles Wright as secretary; Dr.
John W. Evans (medical) with Dr. William E.
Bowlus; Dr. William B. Wiener (obstetrics-gyne-
cology) with Dr. Blanche Lockhard; Dr. James

C. Griffin (surgical) with Dr. R. E. Dunn; Dr.

D. H. Draughn (pediatrics) with Dr. J. Lee
Owen; and Dr. L. C. Hanes (psychiatry) with
Dr. S. Ray Pate.

136

JOURNAL MSMA

Ole Miss Pharmacy
School Ups Standing

The University of Mississippi School of Phar-
macy awarded the fourth highest number of doc-
toral degrees in the nation in 1968-69, according
to a report released this month.

Ole Miss was topped only by Purdue Univer-
sity, 20 doctoral degrees; University of Wiscon-
sin, 17; and Buffalo University, 13. The number
of Ole Miss graduate students receiving Ph.D.
degrees in 1968-69 was eight.

Author of the report is the American Associa-
tion of Colleges of Pharmacy. Included were
summations from 74 institutions in the United
States and four affiliates in Canada.

“One of the crucial tests of an academic insti-
tution revolves around the awarding of doctoral
degrees, not only on a numerical basis but also
qualitatively,” explained Dr. Charles W. Hartman,
dean of the Ole Miss School of Pharmacy.

“In this respect, and using as a standard the
report of the American Association of Colleges
of Pharmacy, our standing is better than ever be-
fore. Our attempts to develop pharmaceutical in-
dustry in Mississippi will be greatly enhanced by
our strong graduate program.”

Dean Hartman also noted that undergraduate
enrollment in the School of Pharmacy reached
357 in September, highest in the history of the
School.

Among current doctoral students at the University
of Mississippi School of Pharmacy , which awarded
the fourth highest number of doctoral degrees in
the nation in 1968-69, are (from left) Everett Solo-
mons of Alston, Ga.; Tony McBride of Lakeland,
Fla.; John Holbrook of Austell, Ga.; and Ed More-
ton of Gulfport.

In the continental United States 4,046 under-
graduates received the bachelor of science or the
bachelor of pharmacy degree during 1968-69, an
increase of 280 or 7.4 per cent over the previous
year.

Otolaryngology Council
Opens Headquarters

The American Council of Otolaryngology has
opened its national headquarters with offices at
1100 17th Street N.W., in Washington, D. C.
John E. Bordley, M.D., of Baltimore, is execu-
tive director and Wesley H. Bradley, M.D., Syra-
cuse, N. Y., is consultant and assistant to the
executive director.

The Council was founded September 1968, in
the District of Columbia to represent the patient
care interests of the nation’s estimated 6,000
otolaryngologists (ear, nose and throat special-
ists).

A general assembly has been created by the
Council to provide a “grass roots forum” in which
the individual specialist may be heard. Repre-
sentation is secured in the assembly from sup-
porting otolaryngologic societies and academies
on all levels, regardless of size.

The American Council is the first national
body designed specifically to represent otolaryn-
gology through the development of national pro-
grams for improved patient care, greater educa-
tional opportunities and to further research. It
now serves as the national voice of otolaryngol-
ogy-

National health problems in the specialty field
of otolaryngology, national manpower needs in
both medical and para-medical areas, develop-
ment of new training programs, assistance of
these programs in the residency and postresidency
levels are all a part of the objectives of the Coun-
cil.

Dr. Bordley is Andelot Professor Emeritus of
Laryngology and Otology, The Johns Hopkins
University School of Medicine, and professor of
environmental medicine, division of audiology
and speech.

Dr. Bradley is clinical associate professor of
otolaryngology at the State University of New
York, Upstate Medical Center, Syracuse, N. Y.

MARCH 1970

137

THE

COST OF

AM BAR
EXTENTABS

IS APPROX! MATELY ONE
HALF THAT OF OTHER LEAP-
ING APPETITE SUPPRESSANTS

AN IMPORTANT FACTOR
IN LONG TERM THERAPY

CONTROL FOOD AND MOOD ALL DAY LONG WITH A SINGLE MORNING DOSE

AMBAR2

One Ambar Extentab before breakfast can

BRIEF SUMMARY/Indications: Ambar

help control most patients’ appetite for up EXTENTABS* suppresses appetite and helps offset emo-

to 12 hours. Methamphetamine, the appe-
tite suppressant, gently elevates mood and
helps overcome dieting frustrations. Pheno-
barbital, the sedative in Ambar, controls irritability and
anxiety. .. helps maintain a state of mental calm and equa-
nimity. Both work together to ease the tensions that erode
the willpower during periods of dieting.

Also available: Ambar #1 Extentabs®— methamphetamine
hydrochloride 10 mg., phenobarbital 64.8 mg. (1 gr.) (Warn-
ing: may be habit forming).

methamphetamine HC1 15 mg.,
phenobarbital 64.8 mg. (1 gr.)
(Warning: may be habit forming).

tional reactions to dieting. Contraindica-
tions: Hypersensitivity to barbiturates or
sympathomimetics; patients with advanced
renal or hepatic disease. Precautions: Administer with cau-
tion in the presence of cardiovascular disease or hypertension.
Side Effects: Nervousness or excitement occasionally noted,
but usually infrequent at recommended dosages. Slight drows-
iness has been reported rarely. See package insert for further
details. a. h. robins company. H-flOBINS

A. H. ROBINS COMPANY,
RICHMOND. VA. 23220

Blue Plans
Promote Mr. Gilliland

Max Gilliland, who joined Blue Cross-Blue
Shield in the Physicians and Hospital Relations
Division last July, has assumed responsibilities
for the south Mississippi territory. Professional

had formerly been han-
dled by Gerald Fran-
ciskato, who is now
manager of the Phy-
sicians and Hospital
Relations Division.

Prior to his asso-
ciation with Blue
Cross-Blue Shield,
Mr. Gilliland was
business manager for
Rush Foundation
Hospital and the
Rush Medical Group
in Meridian. He is a
native of Meridian.

The Physicians and Hospital Relations Divi-
sion is headed by W. C. Mosley, vice president
of Hospital and Physicians Affairs. Director of
the program is C. T. Walker.

Five Care Facilities
To Be Sued

The Social Security Administration has recom-
mended that the Justice Department bring civil
suit against four extended care facilities and a
two-hospital corporation for the return of wrong-
fully collected Medicare payments, Robert M.
Ball, Commissioner of Social Security, announced
today.

Ball also noted that Medicare payments to
another 13 extended care facilities were suspend-
ed after a social security investigation showed
that the institutions had billed Medicare for ser-
vices not medically necessary, and for services of
questionable rehabilitation or therapy value.
There was also billing for services which did not
meet the definition of skilled care in the Medi-
care law, Ball said.

The amount of overpayments received by the
13 institutions is estimated at $1,636,000. Some
of this money has already been repaid and steps
have been taken to recoup the rest. Ball noted.

The five civil suit cases were referred to the

Justice Department after evidence was found that
the institutions, located in Florida, New York,
Arizona, and Illinois, had collected overpayments
for Medicare patients in an amount that could
reach as high as $2,257,600, Ball said.

In a series of “validation” visits begun last
March, Ball said, on-site inspections of institutions
participating in the Medicare program were con-
ducted to check on the validity of payments made
by Medicare intermediaries.

These program validation visits were supple-
mental to the regular contract performance re-
views the Social Security Administration conducts
in the offices of the intermediaries, such as Blue
Cross, Blue Shield, and private insurance orga-
nizations which receive and pay Medicare bills
under contract to the Social Security Administra-
tion.

Commissioner Ball noted that one out of every
12 elderly persons discharged from a hospital,
but still needing skilled nursing care on a con-
tinuous basis, is admitted to an extended care
facility under Medicare. There are about 40,000
such admissions every month, after an injury
or illness requiring hospitalization for three days
or more.

The average Medicare posthospital stay in an
extended care facility averaged 50 days in calen-
dar 1969 and payments totaled between $400
million and $450 million for the year.

To assist the Medicare contractors, the Social
Security Administration has provided data that
helps them to quickly identify irregular practices
and costs.

The identification of an institution which bills
for what is indicated to be an unusual amount of
physical therapy may reveal that services are
being provided, and paid for, without regard to
their medical necessity, and even their potential
harm to elderly patients.

An abnormally large number of bills for phy-
sician visits to patients in extended care facilities
may uncover a practice of “gang” visits. The phy-
sician may be submitting bills for visits to indi-
vidual patients, but in fact reports so many visits
for a given day that he could not have done more
than stopped by the bed.

The Social Security Administration has also de-
veloped information that will enable the Medi-
care contractors to be alerted when a physician
is receiving payments for more services than he
would likely be able to perform under normal
practice. If computer data and investigation show
this to be a problem, these organizations enlist
the help of medical societies to take corrective
action.

MARCH 1970

139

ORGANIZATION / Continued

Ole Miss Develops
Insect Sting Drug

Foresters, campers, soldiers— and even back-
yard gardners — will share the lifesaving benefits
of an emergency drug being developed at the
University of Mississippi.

For those who suffer severe allergic reaction to
the sting of bees, wasps, hornets, yellow jackets
and other insects, the sublingual tablet being de-
veloped at the Ole Miss School of Pharmacy
might prevent shock or death in cases where there
is no time to get an injection or to reach a med-
ical facility.

Dr. Charles W. Hartman, dean of the pharmacy

A hornet’s nest may hold less fear for those who
suffer from severe allergic reaction to stings, due to
research on an emergency drug underway at the
University of Mississippi School of Pharmacy.
‘'Juggling molecules” in an effort to perfect a sub-
lingual tablet for use by allergy victims are (from
left) Dr. Charles W. Hartman, dean of the pharmacy
school, and Dr. Julian H. Fincher, associate pro-
fessor of pharmacy .

school, and Dr. Julian H. Fincher, associate pro-
fessor of pharmacy, are conducting the research.

“Speed of absorption is especially important in
treating severe allergic reaction,” Dean Hartman
explained. “Research on the emergency tablet
was begun in response to an initial request for
an emergency tablet by members of the forestry
department at the University of Georgia, where
some forestry school researchers had developed
severe allergies to stings.”

Since there were no such products available.
Dr. Hartman — who was at the University of
Georgia when the request was made — retained
his interest in the research when he came to Ole
Miss.

There are several problems to be solved. “Not
all drugs can be absorbed under the tongue,” Dr.
Hartman said. “Some drugs are ‘bound’ by sa-
liva. This prevents their being absorbed.”

This particular problem is solved either by
“juggling the molecule,” as Dean Hartman says,
or “changing the physical form of the drug, or
altering membranes of the mouth,” according to
Dr. Fincher, who is conducting the basic re-
search.

“A small dose, if properly designed, allows
absorption within 30 seconds,” Dr. Fincher ex-
plained. “Sublingual medication is especially ef-
fective because of the high amount of blood cir-
culation in the head,” he added.

Both researchers agree that this type of in-
vestigation has been overlooked, and has tre-
mendous potential. “Nitroglycerine is the most
common sublingual medication, and is used for
people who are subject to heart attacks,” Dr.
Hartman said. “This drug was developed earlier
than an allergy tablet because there are many
more people subject to heart attacks than to se-
vere bee-sting allergy.”

“But the development of such a tablet would
be extremely valuable in many situations. The
emergency drug would be particularly applicable
to the military, where you have isolated men who
are away from medical units,” Dr. Hartman said.

A student participated in one phase of the re-
search. Dr. Robert E. Davis, who received the
Ph.D. degree in pharmacy in 1968 and is now
a research scientist with Mead Johnson Labora-
tories, wrote his dissertation on the interactions
of drugs in whole human saliva and simulated
saliva.

140

JOURNAL MSMA

Four MD’s Indicted
for Medicare Fraud

Four physicians and one non-physician have
been indicted in Tampa, Fla, by a federal grand
jury for alleged Medicare fraud estimated at
more than $200,000.

Those charged with “willfully and knowingly
conspiring to defraud” the Medicare program
by making false claims and statements are: Dr.
Harry M. Katz, psychiatrist Dr. Pasquale Louis
Gallizzi, Dr. Alex F. Amadio, Dr. Robert A.
Brewer, and Miss Madge Mathis.

The Florida indictment follows close upon the
conviction of a Florence, S. C., physician for
filing “false information and fraudulent claims”
for payments from Medicare.

Dr. Roy P. Cunningham was sentenced to
eight years in federal prison by U. S. District
Judge Charles E. Simmons on Dec. 22. He was
found guilty on eight counts of submitting false
claims for payment of 432 house calls, for a total
of $6,480. In passing sentence Judge Simmons
said: "It is sad to see a man of Dr. Cunningham’s
background blow his career to the winds.”

Dr. Cunningham is presently being held for
observation for 90 days by the Federal Bureau of
Prisons. After his examination he will be re-
turned to Judge Simmons’ court for final sen-
tencing.

The conviction and sentencing of Dr. Cun-
ningham was the second in the nation for fraud
under the Medicare program. Some 2,500 cases
have been investigated by the Social Security Ad-
ministration during Medicare's 3 Vi -year history.

Social Security Commissioner Robert M. Ball
said that, “We are trying in every way to assure
tight administration of the Medicare program.
Built-in safeguards provide early detection of at-
tempts at abuse and fraud,” he said. “Medi-
care,” the Commissioner noted, “pays about 30
million doctors’ bills and 12 million bills from
institutional providers of services each year. It is
clear from our investigations,” he added, “that
the number of attempts at fraud or abuse is
relatively very small.”

About half of the cases investigated by the
Social Security Administration, he said, resulted
from clerical errors, misunderstandings or honest
mistakes by physicians and health services.

To date, the Social Security Administration
has referred the cases of 13 individuals and or-
ganizations to the Justice Department with the
recommendation for criminal prosecution for
fraud. Another five cases have been referred

with recommendations that civil proceedings be
started for the return of illegally collected funds.

Social security investigators are presently pre-
paring 35 other possible fraud cases for referral
to the Justice Department.

The most common types of alleged violations
reported include physicians and providers billing
for services not rendered, excessive charges, al-
teration of bills, duplicate billing, misrepresenta-
tion of types of services or dates of services,
unreported discounts (kickbacks) and employee
embezzlement.

Dr. Wiygul Is
Named Section Officer

Dr. Frank M. Wiygul. Jr., of Jackson has been
appointed secretary of the Section on Preventive
Medicine of the association’s Scientific Assembly.
The appointment was made and announced by
Dr. James L. Royals of Jackson, president of the
state medical association.

Dr. Wiygul succeeds Dr. Frank K. Tatum of
Tupelo who was elected secretary of the section
in 1969. Dr. Tatum resigned the post following
his recent retirement for reasons of health.

Dr. Royals said that Dr. Wiygul will serve un-
til 1972. As a section secretary, he is also a mem-
ber of the House of Delegates. Chairman of the
section is Dr. Frank J. Morgan. Jr., of Jackson
who is Assistant State Health Officer.

Drs. Webb and Abraham
Are ACOG Fellows

Dr. Henry H. Webb of Jackson and Dr. W. H.
Abraham, Jr. of Meridian will be installed as
Fellows of the American College of Obstetricians
and Gynecologists at its annual meeting. April
12-18, in New York City.

The College, founded to promote the health
and medical care of women, accepts physicians
specializing completely in obstetrics and gyne-
cology, who have successfully completed a clin-
ical examination, and who have been judged by
their colleagues as competent and ethical phy-
sicians.

A Fellow must be a graduate of an approved
medical school and for at least five years prior
to applying for membership in the College he
must have limited his practice to obstetrics and
gynecology.

MARCH 1970

143

MEETINGS

1

NATIONAL AND REGIONAL

American Medical Association, Annual Conven-
tion, June 21-25, 1970, Chicago, Clinical Con-
vention, Nov. 29-Dec. 2, 1970, Boston. Ernest
B. Howard, Executive Vice President, 535 N.
Dearborn St., Chicago, 111. 60610.

Southeastern Surgical Congress, 38th Annual As-
sembly, April 20-23, 1970, Atlanta. A. H. Let-
ton, Secretary-Director, 340 Boulevard, N.E.,
Atlanta, Ga. 30312.

Louisiana-Mississippi Ophthalmological and Oto-
laryngological Society, Annual Meeting, April
3-4, 1970, Biloxi. Arthur V. Hays, Secretary,
3017 13th Street, Gulfport, Miss. 39501.

STATE AND LOCAL

Mississippi State Medical Association, 102nd An-
nual Session, May 11-14, 1970, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Howard A. Nelson, 308 Fulton
St., Greenwood, Secretary.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-
taurant, Hernando. Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday,
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, April and October. Cherie Friedman,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October, Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell, 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March,
June, September, and December. A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday,
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.
W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m., Old Southern Tea Room, Vicksburg.
Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

144

JOURNAL MSM A

Early Filing
Speeds Up Refunds

The number of federal individual income tax
returns filed so far by Mississippi taxpayers is
considerably less than those received for a com-
parable period last year, J. G. Martin, Jr., Mis-
sissippi District Director of Internal Revenue, an-
nounced recently.

Although the deadline for filing is April 15,
both the taxpayer and the government would
benefit if refund returns are filed early.

Mr. Martin pointed out that the Southeast Ser-
vice Center is especially geared for high volume
processing of refund returns early in the filing
season.

Before filing, taxpayers should double check
their Forms 1040 to be sure that all W-2’s are at-
tached, correct social security numbers and ad-
dresses are shown, and related schedules are
attached. In the case of joint returns, both spouses’
signatures are required.

Early federal income tax returns indicate that
many taxpayers are making errors in claiming
adjustments to their income which may delay
their refunds.

The term “adjustments,” as used on the tax

form, refers only to sick pay, moving expenses,
employee business expenses, and payments to
self-employment retirement plans. The total of
these items is entered on Line 15B of the Form
1040.

Some taxpayers are incorrectly reporting on
Line 15b, the total of their itemized deductions,
such as, interest expense, state and local taxes,
contributions, medical, or miscellaneous expenses.
These deductions should be computed and en-
tered on the appropriate schedules as provided in
the instructions.

Taxpayers are also making mistakes by in-
cluding as adjustments the exemption allowances
for themselves, husbands or wives, children, or
other dependents. For taxpayers who use the
tax table to compute their tax, the exemption al-
lowance is already figured into the table. Taxpay-
ers who use the tax rate schedules should make
their computations on Schedule T, which is in-
cluded in the regular tax packet.

To avoid errors in claiming adjustments, it is
suggested that taxpayers read the instructions
carefully and make sure they have attached the
proper supporting documents.

If these precautions are taken, refund checks
should be delivered within five to six weeks from
date of filing.

HIGHLAND HOSPITAL

Asheville, North Carolina

FOUNDED 1904

A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY

Accredited by the Joint Commission on Accreditation and Certified for Medicare

Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho-
therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser-
vice work with families, family therapy and an extensive and well organized activities program, including oc-
cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The
treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may
be realized.

High school facilities for a limited number of appropriate patients are now available on grounds. The School
Program is fully integrated into the hospital treatment program and is accredited through the Asheville School
System.

Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.

Brochures and information on financial arrangements available
Contact: (1) Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions

or

(2) Samuel N. Workman, M.D. (3) Charles W. Neville, Jr., M.D.

Chief of Clinical Services Assistant Professor of Psychiatry

and Medical Director
Area Code 704-254-3201

MARCH 1970

145

ORGANIZATION / Continued

EEG Society Plans
1970 Meeting

The American EEG Society announces that
the 1970 Meeting will be held in Washington,
D. C. at the Shoreham Hotel. The Scientific Ses-
sion is to be held on the 17, 18 and 19 of Sep-
tember, 1970.

Members, as well as nonmembers, are in-
vited to submit abstracts for presentation at the
meeting by June 1, 1970. The abstracts should
be submitted to: Dr. Reginald Bickford, Depart-
ment of Neurosciences, University of California,
La Jolla, Calif. 92037.

Answers to Cancer Quiz

1. D: The male-female ratio is 8:1 except for
lesions of the posterior cricoid region which
are more predominant in women.

2. B: Approximately 96% of laryngeal tumors
are squamous cell carcinomas. Adenocarci-
noma arising from mucous glands is seen oc-
casionally. Sarcomas are rare.

3. False: The true vocal cords are practically
devoid of lymphatic channels and therefore
lesions arising here tend to metastasize late.
The areas above and below the true cords
have a more extensive lymphatic supply and
therefore metastasize early. The area above
the true cords ( supra-glottic region) is
drained by vessels which pass upward, pene-
trate the thyro-hyoid membrane, and end in
the upper deep cervical nodes in the region
of the carotid bifurcation. The area below
the true cords (subglottic region) is drained
by vessels which pass downward to end in
the prelaryngeal, pretracheal, and lower
deep cervical nodes.

4. True: Pain is frequently referred to the ear
through Arnold’s branch of the vagus nerve.
This is more frequent with lesions of the
pyriform sinus, than with lesions of the cords.

5. False: All tumors should be clinically staged
according to location, extent and metastasis.
Treatment is then planned on the basis of
such staging. Systems of clinical staging have
been in use for a number of years and we
are now able to utilize the results of these

studies in establishing the best possible treat-
ment and the prognosis of any given lesion.

6. False: In several large studies hoarseness
was the most frequent presenting complaint.
It is early and usually the only symptom
with lesions of the intrinsic larynx (struc-
tures within the larynx). Lesions of the epi-
glottis and pyriform sinus develop hoarse-
ness rather late, if at all. Other symptoms
are: vague discomfort in the throat, ear pain,
increased secretions, irritable cough, dyspnea,
dysphagia, and a foul smelling breath.

7. False: Node biopsy is contraindicated. In
90-95% of cases presenting with neck nodes
the diagnosis can be made without formal
biopsy of the neck mass. In most cases
endoscopy (laryngoscopy, esophagoscopy,
bronchoscopy, and nasopharyngoscopy) will
reveal a primary lesion which can be bi-
opsied directly. Unnecessary biopsies of neck
masses prior to definitive treatment lowers
the five years survival rate in such cases.

8. B: Radiation therapy is generally the treat-
ment of choice in most small (Stage I) le-
sions of the cords. Surgery achieves the same
five years cure rate, however X-ray leaves
the patient with a better voice.

9. True: In recent years several investigators
have reported a better five year survival
rate in larger lesions of the larynx by em-
ploying low dosage preoperative radiation
therapy followed immediately by surgical re-
section of the tumor and the related lym-
phatic channels.

10. True: When properly carried out such
studies are of great value in determining the
extent of functional impairment and the size
of lesions.

West Miss. Society
Elects Officers

Dr. J. Robert Shell of Vicksburg has been elect-
ed president of the West Mississippi Medical So-
ciety.

Other newly elected officers include Dr. Chester
W. Masterson of Vicksburg, president-elect; and
Dr. M. E. Hinman of Vicksburg, secretary-treas-
urer.

The West Mississippi Medical Society is com-
posed of physicians from Issaquena, Sharkey and
Warren counties.

1 46

JOURNAL MSMA

Taste!

Dicarbosi

ANTACID

Your ulcer patients and
others will love it. Specify
DICARBOSIL 144's-144 tab-
lets in 1 2 rolls.

ARCH LABORATORIES

319 South Fourth Street. St. Louis, Missouri 63102

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The MW-l’s simplicity
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of electrode application
have contributed much
to the popularity of mi-
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and directed. Treatment intensities may be
preset.

Write us for descriptive literature and com-
plete price information.

KAY SURGICAL INC.

663 North State St. * Jackson, Miss.

Index to Advertisers

Arch Laboratories 147

Breon Laboratories 12

Bristol Labs 17

Burroughs-Wellcome 136B

Campbell Soup Company 116A

Highland Hospital 145

Hillcrest Hospital 6

Hynson. Westcott and Dunning, Inc 3

Kay Surgical, Inc 147

Lederle Laboratories 4, 10, 136A

Eli Lilly and Company front cover, 18

Merck, Sharp and Dohme 14, 15, 16

William S. Merrell Company 141

Mississippi Hospital and Medical Service 7

National Drug Company second cover, 132A, 132B

Parke Davis and Co 116D, 128A

Wm. P. Poythress 128D

A. H. Robins Co., Inc 10A, 10B, 138

Roche Laboratories 8, 142, fourth cover

G. D. Searle Co 116B, 116C

Stuart Company 11

Wyeth Laboratories 128B, 128C

Thomas Yates and Company third cover

MARCH 1970

147

OSS (g®SS@lLBSa®M

MSMA Medical Care Plans Department has initiated continuing studies
on why CHAMttrS claims must be returned or rejected. One out of nh
is returned and major reasons are poor description of services ren-'*
dered , f aulty patient identification data from card, and need to
make separate claims. One out of 10 CHAMPUS claims is ineligible
because of unsatisfied outpatient deductibles. Quality of claims : "
excellent, and Review Committee now sees only 2 per cent of total.

*i

AMA Committee on Rating of Mental and Physical Impairment has just
published 12th guide in its series, this time ^Guides to the Evalug
tion of Permanent Impairment - the Skin. 11 Previous guides deal wil
extremities and back, visual system, cardiovascular system, ENT and
related structures, central nervous system, digestive tract, respii-
tory system, peripheral spinal nerves, endocrine system, mental ill
ness, and reproductive and urinary systems. Single copies are free

President Nixon named rising costs, manpower shortages, and insuf-
ficient care for poor most pressing and urgent health care problems
Budget message sent up to Capitol Hill asks more money than ever
before, expanded Hill-Burton program, tighter controls on Medicaid,
and new programs for the poor. Social Security Administration will
get 1,600 more employees and medical education, an additional $25
million. Regional Medical Programs got cut by $3.5 million.

American College of Radiology will pioneer a summer preceptorship
program for medical students. First year students will get chance
to work in diagnostic radiology, while second year level is slated
for training in therapeutic radiology. College foundation will pay
students a stipend of $800 during eight-week training periods which
will be tax-deductible. Idea in program is to recruit residents.

Television is promoting adoptions in California, according to Ameri
can Academy of Pediatrics. Los Angeles County Department of Adopti
goes on air weekly to show off "special needs" youngsters such as t
handicapped. Program has paid off with 202 adoptions out of 282
children appearing on TV. Similar efforts will soon be made in New
York, Washington, Kansas City, and San Francisco.

Volume XI
Number 4
April 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL CONSULTANT
Betty M. Sadler

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
James L. Royals, M.D.

President

Paul B. Brumby, M.D.

President-elect
Walter H. Simmons, M.D.

Secretary-Treasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell
Executive Assistant

CONTENTS

ORIGINAL PAPER

Management of Posterior
Segment Intraocular

Foreign Bodies 149 Morton F. Goldberg,

M.D.

SPECIAL ARTICLE

Radiologic Seminar
XCIV Intravenous

Cholangiography 160 James B. Barlow, M.D.

ANNUAL SESSION

Complete Program 163 Four Days in May

Handbook of the House

of Delegates 1 87 Advance Reports

EDITORIALS

Professional

Corporations:

They’re Here! 191 Our New Law

Complete Care of the

Whole Man 193 Medicine and Religion

Malthus and

Meat Analogs 193 Ersatz, But Good!

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

THIS MONTH

The President Speaking 190 Continuum of Crisis

Medical Organization 198 Pharmacy School Museum

Copyright 1970, Mississippi State Medical Association

SCIENCES LIBRARY

UNIVERSITY OF MARYLAND
BALTIMORE

6

THE JOURNAL FOR APRIL 1970

MSBH Has Social
Services Supervisor

Dr. H. B. Cottrell, executive officer, Missis-
sippi State Board of Health, has announced the
appointment of a supervisor of social services
for the State Board of Health.

He said the newly-created post will be filled
by Miss Geraldine Parish, formerly with the Fam-
ily and Children’s Services of the Mississippi De-
partment of Public Welfare.

“The development of a Social Service Unit in
the State Board of Health can be invaluable in
the coordination and delivery of health services,”
said Dr. Cottrell.

“Social workers,” he said, “can assist in the in-
terpretation of services to patients and in inter-
preting the needs of the patients to the health
workers.

‘They can provide assistance in working with
other agencies — public and private — in planning
for patients. They may participate in training
programs for nurses, mental health programs,
chronic-illness programs, family planning, special
clinics and related services.

“The social worker can assist the county
health departments in organizing community

groups for the promotion of a specific health
service.

“Adding the dimension of social services will,
I’m sure, result in more effective delivery of
comprehensive health services to Mississippians
throughout the state.”

Miss Parish has already participated in neurol-
ogy clinics in Meridian, Hattiesburg, Greenville,
Indianola and Greenwood, working under the
medical direction of Dr. Frank M. Wiygul, Jr.,
director of the Division of General Health Ser-
vices, State Board of Health.

She is currently involved in assisting in plan-
ning a pilot project in Warren County for medical
screening of all persons under 21 who qualify for
Medicaid. After the pilot project gets underway
in March, the service will be extended to all un-
der 21 in the state who are eligible for Medicaid.

Miss Parish is a graduate of the Tulane School
of Social Work, from which she holds a Master
of Social Work degree. While with the Missis-
sippi Department of Public Welfare, she served
as coordinator of children’s services in the Fam-
ily and Children’s Services Division.

Miss Parish is active in the Magnolia Chapter
of the National Association of Social Workers and
is a member of the Academy of Certified Social
Workers. She is president-elect of the Mississippi
Conference on Social Welfare.

HIGHLAND HOSPITAL

Asheville, North Carolina

FOUNDED 1904

A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY

Accredited by the Joint Commission on Accreditation and Certified for Medicare

Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho-
therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser-
vice work with families, family therapy and an extensive and well organized activities program, including oc-
cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The
treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may
be realized.

High school facilities for a limited number of appropriate patients are now available on grounds. The School
Program is fully integrated into the hospital treatment program and is accredited through the Asheville School
System.

Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.

Brochures and information on financial arrangements available
Contact: (1) Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions

or

(2) Samuel N. Workman, M.D. (3) Charles W. Neville, Jr., M.D.

Chief of Clinical Services Assistant Professor of Psychiatry

and Medical Director
Area Code 704-254-3201

April 1970

. ar Doctor:

I v. John Bell Williams signed the association's professional cor-
: ration bill/ HB 48, into law on March 17* Measure permits phy-
i cians to set up tax-qualified corporations under state and fed-
-al statutes, enjoying benefits of retirement plans, group life
d health insurance, sick leave, and tax-free death benefits,
e lead editorial in this issue for report.

Association-sponsored enactment provides for solo M.D. 's
incorporation. Other benefits in excellent law impart
rights under Mississippi Business Corporation Act to
professional corporations. But caution is urged in set-
ting up corporations which must comply with federal law.

:n. Gaylord Nelson (D. ,Wis.) was charged by head of birth control
Iganization as "causing 100,000 unwanted pregnancies. 11 Nelson
bcommittee conducted loaded hearing on The Pill, and FDA obe-
i ently took up cudgel and ordered warnings to patients in oral
:ntraceptive package inserts. Precedent-shattering move con-
:itutes invasion by government in physician-patient relation.

W Undersecretary John Veneman advocates amendments to Medicare
Id Medicaid imposing fee schedules on physicians and hospitals,
neman would pay 75th percentile of 1969 rate. Unexpected op-
sition came from organized labor when California union chief
m Moore said "we don't want wage controls on doctors any more
.an we would want wage controls on union members."

0 more state medical associations are taking over Medicaid fis-
.1 administration from health insurance and prepayment plans,
dical Association of Georgia, an original CHAMPUS administrator ,
in business, while New Mexico Medical Society begins in summer
ter restaffing and acquiring computer. Arrangements were made
' association officers with Assistant HEW Secretary Egeberg.

ugh new regulations have been adopted on reporting payments to
‘oviders of services under Medicaid^ Now required are annual re-
rts to IRS on identity of providers receiving more than $600.
gulations also call for sample verification with recipients that
rvices paid were actually received.

Sincerely,

Rowland B. Kennedy
Executive Secretary

TO

THE JOURNAL FOR APRIL 1970

One of seven dosage forms

Thorazine

“Chlorpromazine HCI

Spansule

■ brand of sustained release capsules

Available in 30 mg., 75 mg., 150 mg., 200 mg. and 300 mg. strengths.

Smith Kline & French Laboratories
Philadelphia, Pa. 19101

MISSISSIPPI STATE MEDICAL ASSOCIATION

Wrong Tables May
Cause Overpayment

So far this year 756 taxpayers in Mississippi
have used the wrong tax table or rate schedule in
computing their 1969 Federal income tax.

Not only have refunds been delayed but many
taxpayers have overpaid their income tax as a
result, reports J. G. Martin, Jr., district director of
Internal Revenue for Mississippi.

The problem occurs when a married taxpayer
filing a joint return uses the tax table for either
married couples filing separately or for single per-
sons. Frequently, single taxpayers use the tables
for married taxpayers by mistake.

There are separate tax tables for single per-
sons, unmarried heads of household, married
couples filing jointly and married couples filing
separate returns. Mr. Martin urged Mississippi tax-
payers to use the right one to avoid mistakes.

Computation from the wrong tax table results

1 1

in the wrong tax due. Some taxpayers, as a result
of the error, receive a smaller, or larger refund
and others receive a bill for additional tax.

Another major reason for refund delay is the
failure of taxpayers to include their correct Social
Security number.

So far this year, 196 refunds have been de-
layed in Mississippi because of incorrect or miss-
ing Social Security numbers, he reported.

Other refunds are being held up for a variety
of other errors or failures to follow instructions
that are included with the returns.

So far errors in arithmetic are causing delay in
sending refunds to 415 taxpayers in Mississippi.

Through last week, there were 1,061 tax re-
turns filed without signatures, including those of
husband or wife on joint returns. These have to
be sent back to the taxpayers before refunds can
be processed.

Mr. Martin said 20,381 taxpayers in Mississippi
have received refunds totaling $3,699,120.45
since Jan.

C/tes t

HOSPITAL

(Formerly Hill Crest Sanitarium)

7000 5TH AVENUE SOUTH
Box 2896, Woodlawn Station
Birmingham, Alabama 35212
Phone: 205-836-7201

A patient centered
independent hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 44 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James A. Becton, M.D., F.A.P.A.

CLINICAL DIRECTORS:

James K. Ward, M.D., F.A.P.A.
Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

HOSPITAL

BIRMINGHAM, ALABAMA

4

Tetrex bidCAPS controls susceptible bacteria
on an easy b.i.d. schedule at a cost lower than
all other “convenience dosage” tetracyclines.

PRESCRIBING INFORMATION. For complete information consult
Official Package Circular. Tet. Comb. 1-7/17/67. Indications: Infections
of respiratory, gastrointestinal and genitourinary tracts and skin and soft
tissues due to tetracycline-sensitive organisms. Contraindications: The
drug is contraindicated in individuals hypersensitive to tetracycline
Warnings: Photodynamic reactions have been produced by tetracyclines.'
Natural and artificial sunlight should be avoided during therapy. Stop
treatment if skin discomfort occurs. With renal impairment, systemic
accumulation and hepatotox-
icity may occur. In this situa-
tion, lower doses should be
used. Tooth staining and
enamel hypoplasia may be in-
duced during tooth develop-
ment (last trimeter of preg-
nancy, neonatal period and

IcfrcXlririCAI’S

(TETRACYCLINE PHOSPHATE COMPLEX)

childhood). Precautions: Mycotic or bacterial superinfection may o
Infants may develop increased intracranial pressure with bulging
tanels. In gonorrheal therapy, serologic tests for syphilis should be
ducted initially and monthly for 4 months. Adverse Reactions: Glos
stomatitis, nausea, diarrhea, flatulence, proctitis, vaginitis, derma
and allergic reactions may occur. Usual Adult Dose: 1 Gm./day in
4 divided doses. Continue therapy for 10 days in Group A Beta-h<
lytic streptococcal infections. Administer one hour before or 2 h

®after meals. Supplied: (
sules— 250 mg. in bottles c
and 100. bidCAPS-500 m
bottles of 16 and 50.

A.H.F.S. Category
BRISTOL
LABORATORIES

BRISTOL

Division of Bristol-Myers C<
Syracuse, New York 13201

• '

a g Spots End Washington - TV networks get a last bonanza

; Cash Blast on cigarette advertising with change of one

day on permanent ban by the House and Senate,
flaw was delayed one day, becoming effective Jan. 2, 1971,
’itting all-out swan song by tobacco manufacturers in bowl
i telecasts New Years Bay. Compromise law can't touch printed
.but will require tougher package warning on fags.

s are White New York - A Health Insurance Institute study
l ar Killers concludes that office workers are surrounded

bby potential assassins, chairs, stairs, file
ets, and elevators. Five-year survey disclosed that falls in
es are leading cause of injury and disability for employees
his order: Falls in corridors, chairs, stairs, escalators,

elevators. Study also showed that employees themselves are
^onsible for mishaps, rather than faulty equipment.

i Administrators Washington - Administrators of nursing homes
; Be Licensed and extended care facilities must be licensed

by states on July 1, 1970, if facility is to
.ify for Medicaid payments. Requirement leaves licensure to
;es as well as minimum qualifications for licensing. Federal
ilation has one-year grandfather clause as well as two-year
risional licensure during which applicant may qualify.

lents Hit $71 Jackson - Health insurance and prepayment paid
Lion in State Mississippians $71 million in benefits during

1969, reports the Health Insurance Institute,
lercial companies paid $43.4 million, while Blue plan and other
governmental sources paid just over $27 million. HII says that
million Mississippians under 65 had coverage last year for medi-
care. Other findings showed average daily hospital census of
)0 patients and 300,000 admissions during '69 for Mississippi.

. Tax Proposed Atlanta - Former FBA chief James Goddard has
Addiction Care proposed a penny-a-pill tax on tranquilizers

and stimulants to pay for care of drug abuse
.ents and to finance nation-wide education program. Dr. Goddard
\ that unique tax would raise $160 million annually. Observers
>d that extension of tax to every pill listed as subject to abuse
Ld produce upwards of $500 million per year.

THE JOURNAL FOR MARCH 1970

1 4

Individual’s Health
Burden Eased

In a time when annual medical care expendi-
tures have soared to $60.3 billion, the govern-
ment’s health care programs are significantly eas-
ing the individual’s financial burden, according to
a chart booklet on medical costs published by the
Social Security Administration.

The booklet, “The Size and Shape of the
Medical Care Dollar,” was prepared by the Ad-
ministration’s Office of Research and Statistics
and covers the period from 1950 through the
end of fiscal year 1969.

As detailed in the booklet’s charts, medical
care expenditures during that 19-year period in
the United States have increased almost five
times over, markedly climbing from the $12.1 bil-
lion that was spent on health care in 1950. To-
day’s medical care dollars now account for a 6.7
per cent share of the Gross National Product; in
1950, medical expenses made up 4.6 per cent
of the GNP.

At the same time, however, it is noted that the

percentage of medical costs borne by the indi-
vidual has actually decreased in the last several
years — and especially since 1966 — after enact-
ment of Medicare and Medicaid.

Throughout the 36-page booklet, the Social
Security Administration takes note of “rising
health costs,” and at one point lists 10 steps that
the Federal Government is taking to “insure that
the nation gets more for its health dollar.”

Among those steps are included the use of
stricter guidelines for hospitals and nursing homes
which are participating in the Medicare program,
and the promotion of less expensive alternatives
to inpatient medical care for individuals who
would benefit from more economical care.

The chart booklet notes that the largest
growth in medical spending from 1950 was due
to increases in prices of everything from hos-
pital services to doctors’ fees.

As noted in the text accompanying one of the
booklet’s charts, “A dollar of health care spent
today does not go nearly as far in paying for a
day of care or a unit of service as it would have
several years ago.” In fact, from 1965 to 1968,
medical care prices jumped almost twice as fast
as prices for all consumer items.

LAKELAND NURSING CENTER

“MISSISSIPPI’S NEWEST”

A 105 BED EXTENDED CARE FACILITY, MEDICARE APPROVED, EQUIPPED FOR REHABILI-
TATION OF THE SICK WITH PHYSICAL THERAPY, INHALATION THERAPY, SPEECH THER-
APY AND OCCUPATIONAL THERAPY. OPEN STAFF. FULL TIME MEDICAL DIRECTOR AND
EMERGENCY MEDICAL CALL COVERAGE.

For Admission Call:

WILLIAM F. KLIESCH, M.D.
MEDICAL DIRECTOR AND ADMINISTRATOR
3680 LAKELAND LANE
JACKSON, MISSISSIPPI
DIAL 982-5505

Symptoms subside
in 48 to 72 hours!

Itching, burning, discharge,
and malodor disappear rapidly...
patient’s embarrassment, too.

Avoids the
disappointment
of “the cure
that didn’t take.”

Candeptin is“cidal"as well as“static,”
it is 100 times more potent in vitro
than nystatin,2 and it has achieved
culture-confirmed cure rates of
90% and more3 (even in notoriously
d iff icu It-to-treat pregnant patients)!-3'4

And two weeks does it.

Usually, Candeptin cures in
a single 14-day course of therapy.3

the fortnight fungicide

Candeptin

candicidin

Vaginal Tablets/Ointment

Formula: CANDEPTIN Vaginal Ointment con-
tains a dispersion of candicidin powder equiva-
lent to 0.6 mg. per gm. orO 06% candicidin activity
in U.S.P. petrolatum. 3 mg. of candicidin is con-
tained in 5 gm. of ointment or one applicatorful.
CANDEPTIN Vaginal Tablets contain candicidin
powder equivalent to 3 mg. (0.3%) candicidin ac-
tivity dispersed in starch, lactose and magnesium
stearate.

Indications: Vaginal moniliasis due to Candida
albicans and other Candida species.

Contraindications: Patient sensitivity to any
of the components. During pregnancy manual
tablet insertion may be preferred since the use of
the ointment applicator or tablet inserter may be
contraindicated.

Caution: Clinical reports of sensitization or tem-
porary irritation with CANDEPTIN Vaginal Oint-
ment or Vaginal Tablets have been extremely
rare. To avoid reinfection, it is recommended that
the patient refrain from sexual intercourse during
treatment or the husband wear a condom.
Dosage: One vaginal applicatorful of CAN-
DEPTIN Ointment or one Vaginal Tablet is
inserted high in the vagina, twice a day, in the
morning and at bedtime, for 14 days. Treatment
may be repeated if symptoms persist or reappear.
Dosage forms: CANDEPTIN Vaginal Ointment
is supplied in 75 gm. tubes with applicator (14-
day regimen requires 2 tubes) CANDEPTIN Vag-
inal Tablets are packaged in boxes of 28, in foil,
with inserter — enough for a full course of treat-
ment. Store under refrigeration.

Federal law prohibits dispensing without pre-
scription. CANDEPTIN is a registered trade-mark
of Julius Schmid, Inc.

References: 1. Olsen, J R. Journal-Lancet
85 287 (July) 1965 2 Lechevalier, H : Antibiotics
Annual 1959-1960, New York, Antibiotica, Inc.,
1960, pp 614-618 3. Giorlando, S. W„ Torres, J. F„
and Muscillo, G Am J Obst & Gynec. 90 370
(Oct. 1) 1964. 4. Friedel, H J.: Maryland M. J.
75 36 (Feb.) 1966.

Julius Schmid Pharmaceuticals
423 West 55th Street
New York, N.Y. 10019

Few Tax Changes
Affect 1969 Returns

Receipts of individual tax returns are down
nine per cent from last year, announced J. G.
Martin, Jr., District Director of Internal Revenue
Service. Only 8.1 million federal income tax re-
turns had been filed by mid-February.

Many taxpayers appear to be needlessly de-
laying their refunds by waiting for additional in-
structions on the new tax law. Most of the
changes made by the Tax Reform Act of 1969
relate to 1970 and later years, and affect only a
small percentage of individual income tax re-
turns for 1969, Martin said.

Changes affecting returns for 1969 that must
be filed by April 15 involve living expenses paid
by insurance as a result of home damage or de-
struction; sales of collections of letters, memos,
etc.; gains from certain installment sales; de-
preciation and amortization; and investment
credit.

Under the new law a taxpayer whose home is
damaged by storm, fire, or other casualty does
not have to pay tax on the insurance proceeds
he receives for temporary living expenses. The
amount not subject to tax is limited to actual ex-
penses that are over and above normal living ex-
penses.

Gains from sales made by a taxpayer after
July 25, 1969, of collections of letters and docu-
ments that were created by or for him will be
taxed as ordinary income rather than capital
gains.

Sales of real property and casual sales of per-
sonal property made after May 27, 1969, for a
price of more than $1,000 are subject to new
rules in cases when the seller reports his gain in
installments extending over two or more years.

The investment credit in most cases ended
April 18, 1969; however, the investment credit
is available for property bought, built or rebuilt
under a binding contract entered into before April
19, 1969, or in certain other transitional sit-
uations.

The use of accelerated depreciation of real
property acquired after July 24, 1969, has been
limited, but a 60-month write-off of air or water
pollution control facilities has been added for
1969 returns.

Taxpayers concerned with these matters for
their 1969 returns may find it helpful to obtain a
new publication “Highlights of 1969 Changes in
the Tax Law” — IRS Publication 553 — available
free from IRS district offices.

THE JOURNAL FOR APRIL 1970

1 8

Each tablet contains
erythromycin esioiaie
equivalent to 125 mg.
erythromycin base.

Each 5 cc. contain
erythromycin estolate
equivalent to 250 mg.
erythromycin base.

When mixed as directed,
each 5 cc. will contain erythromycii
estolate equivalent to 125 mg.
erythromycin base.

When mixed as
JF directed, each cc.

will contain
erythromycin estolate
equivalent to 100 mg.
erythromycin base.

Each 5 cc. contain
erythromycin estolate
equivalent to 125 mg.
erythromycin base.

The many
forms
of llosone

Erythromycin Estolate

Each Pulvule® contains
erythromycin estolate
equivalent to 125 mg.
erythromycin base.

Additional

available upon request.

Eli Lilly and Company
Indianapolis, Indiana 46206

Each Pulvule contains
erythromycin estolate
equivalent to 250 mg.
erythromycin base.

900761

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

April 1970, Vol. XI, No. 4

Management of Posterior Segment
Intraocular Foreign Bodies

MORTON F. GOLDBERG, M.D,

Arlington, Virginia

Management of posterior segment intraocular
foreign bodies has always been complex. Al-
though recent technical advances have facilitated
the extraction of such objects, the prognosis for
retention of an eye and for restoration of normal
visual acuity remains guarded even in the most
favorable circumstances. Optimal clinical man-
agement depends upon the following factors: (1)
accurate localization of the foreign body; (2)
knowledge of its composition; (3) awareness of
the extent of the ocular trauma; (4) the proper
decision on whether to remove the foreign body
or to leave it in situ; and (5) once undertaken,
technical excellence in the actual removal of the
foreign body.1

The possibility of a retained intraocular for-
eign body should be considered in every perfo-
rating ocular injury.1 Retained foreign bodies can
lodge anywhere on the surface of the globe or
within its wall, or can be buried within any of its
various intraocular tissues. Common sites for re-

Consultant in Ophthalmology, Neurological and Sensory
Disease Control Program, U. S. Public Health Service.
Presented in part at the 101st Annual Session of the
Mississippi State Medical Association, Biloxi, May 15,
1969.

tained intraocular foreign bodies are as follows:
anterior chamber, 15 per cent; lens, 8 per cent;
posterior segment, 70 per cent; and orbit (double

Recent technical advances have facilitat-
ed the extraction of posterior segment intra-
ocular foreign bodies. However, the prog-
nosis for retention of the eye and for restora-
tion of normal visual acuity remains guard-
ed even in the most favorable circumstances.
The author discusses the factors involved in
optimal clinical management: localization
of the foreign body, knowledge of its com-
position, awareness of the extent of the ocu-
lar trauma, the proper decision on whether
or not to remove the foreign body and the
technique required in removal.

perforation), 7 per cent.2 The detection of a sin-
gle foreign body in any one of these locations
should not provide a sense of false security, since
multiple intraocular foreign bodies are not un-
common. This is particularly true in modern in-

APRIL 1970

149

INTRAOCULAR BODIES / Goldberg

dustrial and military accidents in which the eye
may be subject to a barrage of missiles from ex-
plosions and other incidents.

Although there are many techniques for indi-
rect demonstration of an intraocular location, the
most important single maneuver in the determi-
nation of appropriate therapy for any patient is
direct visualization of the foreign body. This is
particularly important, because double perfora-
tion of the globe may have occurred. In such
cases, it is sometimes difficult to know, in the
presence of opaque ocular media, whether or not
the foreign body remains inside the eye. If one
has direct visualization of the foreign body, how-
ever, there is no doubt as to its location, and sub-
sequent decisions regarding possible removal can
be made more easily.

IMPORTANT MANEUVERS

Since a penetrating injury complicated by an
intraocular foreign body results in post-traumatic
inflammatory processes, many of which tend to
cloud the ocular media, certain immediate ma-
neuvers should be performed upon examining the
patient. Immediate and maximum pupillary dila-
tation is probably the most important. Because of
the complicating factors of post-traumatic miosis,
iridocyclitis, cataract, vitreous hemorrhage or in-
flammation, or hypotony, the first examiner is
sometimes the only person who has an opportuni-
ty to examine through clear ocular media. Any
delay in visualization of the posterior segment
can result in failure to detect the presence of an
intraocular foreign body, a double perforation, or
associated intraocular injuries such as ricochet
wounds in the retina or trauma to the macula or
optic nerve.

Severe iritis can occur within minutes or hours
following trauma, and a profuse collection of in-
flammatory debris can obscure a small pupil and
contribute to early posterior synechiae in a state
of pupillary miosis. Traumatic cataract formation
can similarly occur within minutes or hours, and
an initially transparent lens, which allows careful
inspection of the posterior segment, can progress
to a totally opaque structure, which precludes
any accurate determination of the state of the
posterior segment of the eye. In addition, an early
vitreous hemorrhage may be confined to one area
of the vitreous chamber, but the effects of time,
gravity, and motion of the globe may all con-
tribute towards dissemination of the blood within
the vitreous chamber, with subsequent and con-
sequent loss of transparency and visibility.

With regard to immediate visualization of the
posterior segment of the eye, binocular indirect
ophthalmoscopy remains the best and most im-
mediately available technique. The power of the
illuminating bulb, the ability to achieve stereop-
sis, and the capacity to examine most, if not all,
of the posterior segment make the binocular in-
direct ophthalmoscope indispensible for an accu-
rate and complete diagnosis. Although the mo-
nocular, direct ophthalmoscope is useful in cer-
tain circumstances, it does not approach the use-
fulness and versatility of the binocular indirect
ophthalmoscope. This is particularly true when
the ocular media have already become partially
opaque. Occasionally, the slit lamp, with or with-
out use of a three-mirror contact lens, is useful in
locating foreign bodies in the anterior or periph-
eral vitreous chamber.

Indirect demonstration of intraocular foreign
bodies is rarely as convincing as direct visualiza- i
tion but occasionally is highly useful because of
the presence of totally opaque ocular media.
There are three general types of indirect demon-
stration of intraocular foreign bodies: (1) radio-
logic procedures; (2) foreign body locators; and
(3) ultrasonic probes.

ORBITAL RADIOGRAPHS

Routine, plain, orbital radiographs can occa-
sionally be very useful, even in the presence of
small foreign bodies, if certain precautions are
observed in obtaining them. Whenever possible,
new cassettes should be utilized, because older,
extensively used cassettes frequently have a vari-
ety of small radiopaque markings from accumu-
lated debris or mishandling, and the final x-ray
often shows artifacts simulating intraocular or in-
traorbital foreign bodies. If new cassettes are un-
available and a foreign body appears to be pres-
ent, the same view should be repeated with a dif-
ferent cassette. This will have a different set of
artifacts, but should not reproduce any suspicious
radiopacity seen on the initial film. Two radio-
logic views are useful in the detection of intra-
ocular foreign bodies: An anteroposterior view
and Belot’s modified lateral view, which imposes
only the shadow of the thinned lateral wall of the
bony orbit upon the area of the globe.2

The A-P view and modified lateral view
should be repeated with the eyes in a new posi-
tion of gaze, either maximum supraduction or
maximum infraduction. To prevent artifactitious
movement of the foreign body, the patient’s head
can be immobilized with a bite-board. If there is
no shift in position of the foreign body on maxi-
mum change in gaze, it is unlikely that it lies

150

JOURNAL MSM A

within the globe. On the other hand, if the foreign
body does, in fact, shift, it can be either intra-
ocular in location or can be attached to the out-
side wall of the eye or to one of the extraocular

muscles.

In all such x-ray studies, fixation and immobil-
ity of the head are of paramount importance,
since motion blurs the image of a foreign body. If
the foreign body is small, its image may be ob-
scured against the background of radiopaque
bony tissues. Similarly, a short exposure time
(preferably less than 0.5 seconds), a short film
distance designed to minimize distortion (about
24 inches), fast film, and soft x-rays (so that the
cornea-air interface can be seen on lateral views)
will all maximize the ability to detect foreign
bodies whose density would otherwise make ra-
diologic demonstration difficult. If there is any
doubt of the ability of x-rays to demonstrate an
intraocular or intraorbital foreign body, one can
tape residual debris, presumably similar in nature
to the offending object itself, to the x-ray cassette
prior to making the exposure.

SCREENING TESTS

A quick screening test of considerable value
i utilizes a 25-cent coin.1 When the 25-cent coin is
I placed in the center of an anteroposterior x-ray
i of the orbit, it approximates the average diame-
i ter of the globe (24 mm.). Consequently, any
radiopaque foreign body lying outside the cir-
cumference of the 25-cent piece is, of necessity,
located outside the average-sized eye. If the shad-
ow of the foreign body is covered by the coin, it
may be in an intraocular location, but other con-
firmatory tests are required.

The bonefree technique of orbital x-rays is in-
valuable in demonstrating small foreign bodies or
foreign bodies whose density approaches that of
orbital bone; for example, aluminum. In taking
bonefree views, dental x-ray film is utilized in
both lateral and anteroposterior directions. In the
lateral approach, the x-ray film is pressed into the
area of the medial canthus, and the x-ray tube is
directed from the lateral position.1 The eye, of
course, should be anesthetized topically, and the
manipulation should be performed by an individ-
ual who is accustomed to handling ocular tissues.
Pressure should not be applied on an eye with an
open perforation.

For the anteroposterior projections, the x-ray
film can be placed in the superior and inferior
conjunctival cul-de-sacs or in the upper lid recess,
and the x-ray is projected through the globe onto
the film. Glass foreign bodies are ordinarily very
difficult to demonstrate radiologically unless they

contain barium or lead. With the bonefree tech-
nique, they can be visible, regardless of their
metal content.

RETROBULBAR INJECTION

Occasionally a foreign body will be located
near the posterior pole of the eye, and there is
doubt as to whether or not it is intra- or extra-
ocular. In such circumstances a retrobulbar in-
jection of an aqueous solution of radiopaque ma-
terial (such as Hypaque) can be used to outline
the posterior contour of the scleral shell. A lateral
view can then demonstrate whether or not the
radiopaque material lies posterior to the foreign
body, in which case it is presumed that the foreign
body is in an intraocular location.

More precise radiopaque localization tech-
niques include the following: Sweet’s technique,
Comberg’s technique, Spindell’s technique, and
the use of radiopaque scleral markers.1-3 The
first three of these techniques have in common
the fallacy that all eyes have identical standard
dimensions. It is usually assumed that the aver-
age eye is 24 mm. in diameter. However, the
adult human eye varies from about 20 mm. to 26
mm. in diameter. This range of dimensions is in-
creased in abnormal refractive states such as in
high myopia or high hyperopia. In practice,
therefore, the foregoing techniques are subject to
significant error when they localize foreign bodies
within a millimeter or so of the scleral shell. In
cases of high myopia, for example, a foreign
body may be localized just posterior to the globe
(using an average diameter of 24 mm.) when, in
fact, the foreign body may actually be within the
globe. The reverse situation may be true of high
hyperopia, wherein the localization procedures
ostensibly demonstrate an intraocular location
when, in fact, the foreign body may be lying a
few millimeters posterior to the globe. Nonethe-
less, the localization techniques of Sweet, Com-
berg, and Spindell are useful in most clinical situ-
ations.

The Sweet technique remains the standard ra-
diological localization procedure. It is based upon
a triangulation principle and utilizes a small radi-
opaque device which is positioned at a known
distance in front of the eye.2 Unfortunately, the
range of error is 2-4 mm., especially if the foreign
body is in a posterior location. However, its ad-
vantages are that the apparatus used for the ra-
diographic procedure does not touch the injured
eye, and the radiologic image of the localizing
device is not superimposed on the image of the
foreign body. The major disadvantages include
the assumption that the eye is 24 mm. in diame-
ter; the error of 2-4 mm.; and the difficulty of

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INTRAOCULAR BODIES / Goldberg

maintaining immobility of the patient’s head and
complete fixation of the eye. Finally, this pro-
cedure is difficult for the inexperienced radiolo-
gist.

The Comberg technique utilizes a contact lens
with radiopaque markers and is more accurate
than the Sweet technique, since the markers ac-
tually touch the eye, thereby reducing the error
of radiologic magnification. This technique is also
advantageous in that the radiodensity of the lead
markers allows a qualitative interpretation of the
nature of various foreign bodies. Disadvantages
of the Comberg technique include the standard
assumption of the 24 mm. eye; possible superim-
position of the contact lens markers on the image
of the foreign body; contact of the lens with an
injured eye, possibly inducing infection or addi-
tional trauma; difficulty of applying a contact lens
to a nervous or a young patient; and. finally, im-
proper positioning of the lens due to the presence
of chemosis or a deformed anterior segment.

SPINDELL TECHNIQUE

A more recently published technique by Spin-
dell includes the use of orbital laminograms taken
in conjunction with a specially designed radi-
opaque spectacle frame.3 Again, the assumption
of a 24 mm. eye could contribute to an inaccurate
localization.

Radiopaque scleral markers provide a very ac-
curate means of localizing foreign bodies within
the eye but require aseptic technique. Thus, this
procedure is usually reserved for operating room
usage. In performing these maneuvers, needles
or other radiopaque markers are inserted into the
sclera in various locations, and a series of bone-
free x-rays or standard orbital views is taken. The
markers are then moved until they are superim-
posed in both anteroposterior and lateral projec-
tions on the image of the foreign body. They
thus provide accurate external localization of an
intraocular object.

Foreign body locators, typified by the Berman
apparatus, can be useful, particularly when for-
eign bodies are composed of certain materials or
when they are found in certain locations. The
Berman apparatus is especially responsive to
iron-containing and carbon steel-containing for-
eign bodies, as well as to foreign bodies of pure
nickel. It is not well suited for detection of alloy
steels, coin nickel, brass, copper, lead, or alumi-
num. The reactivity of the locator is directly re-

lated to the size and to the magnetic or conduc-
tive properties of the foreign body. For example,
the detecting range for an iron-containing object
is about 10 times the diameter of the foreign
body; e.g., a 1 mm. iron foreign body is detecta-
ble at a distance of about 10 mm.2 For nonmag-
netic metals, foreign bodies are detectable within
one to two times their own diameter. Thus, for
the sake of practicality, a non-magnetic foreign
body has to be greater than about 3 mm. in di-
ameter in order to be detected by the Berman
locator.

DISADVANTAGES

Disadvantages of such apparatuses in locating
intraocular foreign bodies include the fact that
foreign bodies may shift their position at the time
of surgery (after completion of the localization
procedure). The locator is most valuable for de-
tecting a foreign body which is embedded pos-
teriorly in the wall of the eye, and a direct trans-
scleral cutdown or extraction is contemplated. It
is also useful in locating foreign bodies in Tenon’s
capsule, which otherwise resembles finding a
needle in a haystack.

More recently, A-mode ultrasonic probes have
been evaluated as foreign body locators.4 While
foreign bodies can usually be detected in intra-
ocular locations by these devices, it has recently
been determined that the Sweet technique is more
accurate, because, should a foreign body lie in a
tissue interface such as the wall of the eye, it can-
not be ultrasonically distinguished from that in-
terface.4

SILENT FOREIGN BODIES

Despite the widespread use of the foregoing
techniques, there are certain foreign bodies
which remain silent and undetectable. Various
clues provide suspicion that the eye harbors such
objects. These clues include the following: focal
bedewing; a biomicroscopically visible corneal or
vitreous tract; angle trauma with peripheral an-
terior synechiae or angle recession; iridotomy or
iridodialysis (sometimes best visualized by retro-
illumination); heterochromia; anisocoria or pu-
pillary irregularity; sector zonulolysis; persistent
hypopyon; persistent uveitis; or possibly a focally
tender ciliary body (overlying the site of a for-
eign body).

One factor determines to a large extent the
success or failure of an attempt at removal of an
intraocular foreign body; namely, its magnetic
properties. Iron, pure nickel, cobalt, and some
manganese alloys are magnetic, and, consequent-
ly, can be extracted from the eye with minimal

152

JOURNAL MSM A

trauma. Iron-containing foreign bodies are par-
ticularly dangerous because they commonly cause
siderosis bulbi. In this disease, iron is deposited
in intracellular locations throughout the eye, re-
sulting ultimately (in about two months to two
years) in retinal degeneration, cataract, discolor-
ation of the uveal tissues, or absolute glaucoma.
It is thus fortunate that iron-containing foreign
bodies can usually be extracted atraumatically by
a magnet.

COPPER BODIES

Copper-containing foreign bodies can produce
an acute, sterile, chemical, purulent panophthal-
mitis if the foreign body is composed of a high
concentration of copper (greater than about 85
per cent) or if the copper is present on the out-
side of the foreign body in high concentration,
from which it can diffuse into the surrounding
ocular tissues.2 Such a disastrous complication
usually occurs in the immediate post-traumatic
period. On the other hand, a more chronic and
less serious course of copper deposition on the
membranes of the eye (Descement’s membrane,
lens capsule, etc.) can occur, resulting in the con-
dition known as chalcosis. Such an eventuality is
not nearly as common nor as detrimental to the
visual status of the eye as is that from an iron-
containing foreign body. The Kayser-Fleischer
ring and sunflower cataract, produced by deposi-
tion of copper in the cornea and in the lens cap-
sule, mimic those seen in Wilson's hepatolenticu-
lar degeneration. They, themselves, are not re-
sponsible for visual disability, but ocular degener-
ation and blindness can definitely occur from
chalcosis.

In order to determine the chemical nature of
certain unknown intraocular foreign bodies, the
surgeon can perform an anterior chamber para-
centesis and chemically analyze the aqueous hu-
mor for such substances as copper, aluminum,
magnesium, and lead. Similarly, he can indirectly
determine the nature of certain retained objects
by attaching a spectroscopic ocular to a slit lamp.
More directly, if there is residual debris from the
material causing the ocular penetration, the for-
eign material itself can be chemically analyzed.

OCULAR REACTIVITY

Knowledge of the ocular reactivity of these
substances enables the surgeon to vary the ag-
gressiveness with which he pursues the extraction
of intraocular foreign bodies. In decreasing order
of ocular reactivity the following substances can
be listed: iron, copper, mercury, aluminum, nick-
el, zinc, lead, precious metals, glass, plastics, etc.2

Of these all are nonmagnetic except iron and
pure nickel.

As in all perforating injuries, exquisite consid-
eration for the potential development of sympa-
thetic ophthalmia is an absolute requirement.
Careful biomicroscopic evaluation of the non-
penetrated eye should be part of the daily exam-
ination ritual, in order to determine if there are
early signs of inflammation. Any consideration
towards definitive therapy should involve the pos-
sibility of enucleating the injured eye within the
first eight or ten days of the traumatic episode in
an effort to forestall the development of sympa-
thetic ophthalmia. If good visual acuity remains
and the perforation can be surgically repaired
without significant damage to the eye, the physi-
cian is justified in attempting to retain the in-
jured eye. In making the decision on whether or
not to enucleate the injured eye, the perforating
effects of the trauma must be assessed in conjunc-
tion with the blunt contusive effects, the immedi-
ate chemical effects, and the immediate inflam-
matory effects. In addition, an informed judgment
as to the probable consequences of subsequent
chemical, inflammatory, and reparative processes
must be included in the over-all judgment of the
clinical situation.

SALVAGING THE EYE

At the time of initial surgical repair of the
wound of entry, all efforts should be expanded in
the attempt to salvage the eye. Seemingly hope-
less situations, characterized by gaping wounds,
avulsed tissue, prolapsed intraocular contents,
and extensive hemorrhage can occasionally be
converted into much more favorable circum-
stances by virtue of a meticulous surgical restora-
tion. If accurate projection of light is lost during
the first post-traumatic week or two, enucleation
is probably then in the best interests of the pa-
tient. Occasionally, immediate enucleation is jus-
tified, as in the case of total disruption of the
globe from a bullet’s direct hit.

Since intraocular foreign bodies can cause rico-
chet wounds in the retina or can produce double
perforations, complete retinal evaluation should
be performed in salvageable cases, so that any
retinal break or scleral wound of exit can be
treated at the time of closure of the wound of en-
try or at the time of foreign body extraction.

The decision to attempt removal of the foreign
body is determined by weighing the contusive, in-
flammatory, and chemical effects of the initial
trauma and its probable later inflammatory,
chemical, and fibrotic effects (together with the
effects of subsequent surgical trauma) plus the

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153

INTRAOCULAR BODIES / Goldberg

possible inability to remove the foreign body. In
most cases, with or without surgical intervention,
therapy with systemic and local antibiotics and
corticosteroids is warranted. Early inflammatory
changes are, as noted previously, sometimes the
result of sterile chemical processes, especially
from copper. If this appears to be the case (and
such a likelihood can be corroborated by chem-
ical analysis of material remaining from the acci-
dent, particularly if the copper content is greater
than 85 per cent), immediate removal of the for-
eign body is then the only way to alleviate the
inflammatory process, despite the inherent dan-
gers of operating on an acutely and severely in-
flamed eye.

CHRONIC EFFECTS

Chronic inflammatory, chemical, and fibrotic
effects are more or less inevitable, depending
largely upon the chemical nature of the foreign
body and on its intraocular location. They are
particularly likely to occur in iron-containing for-
eign bodies, particularly when the iron is in a rel-
atively pure state. Thus, a surgeon would ordi-
narily be more aggressive in attempting to re-
move such a retained object. The magnetic char-
acteristics of the iron-containing foreign body
would enhance his willingness to perform the sur-
gery because of the applicability of magnetic ex-
traction.

The opposite situation pertains to a non-mag-
netic foreign body such as a copper-containing
alloy with low concentration of elemental copper.
In such a circumstance the ultimate effects of
chalcosis are ordinarily nowhere near as severe
as in acute copper panophthalmitis, and not usu-
ally as severe as with a retained iron-containing
foreign body. Thus, there would not be as high a
priority to remove such a foreign body. The inap-
plicability of the magnet and the consequent re-
quirement for more traumatic surgery would sup-
port this conservative judgment.

THERAPEUTIC JUDGMENT

The unwillingness of a surgeon to attempt ex-
traction of a certain foreign body may be due to
the fact that it is nonmagnetic, that it is invisible,
or that it is trapped in fibrotic tissue or in inflam-
matory debris. Withholding surgery in those cases
where extraction appears difficult should not be
misconstrued as lack of courage or ability. The
availability of surgical techniques in certain in-
stances is simply not advanced enough to provide
safe or successful manipulation within the globe.

154

Assuming that the foreign body remains in situ, ;
inevitable destruction of the eye, even in iron-
containing foreign bodies, may not occur. Certain
foreign bodies may induce enough surrounding
encapsulation that no diffusion of toxic or chem-
ical substances occurs. Total dissolution of the
foreign body without induced chemical changes
may similarly occur, and spontaneous expulsion
of the foreign body from a globe without at-
tendant destruction of the eye has also been re-
ported.2

In summary, decision to remove a foreign body
or to leave it within an eye requires the exercise
of mature therapeutic judgment. The decision-
making process is exceedingly difficult in certain
cases, and the patient should realize that pene-
trating injuries and retained ocular foreign bodies
produce guarded prognoses, both for visual acui-
ty and for retention of the globe, whether or not
the foreign body is extracted or is allowed to re-
main within the globe.

AVAILABLE MAGNETS

Several magnets are available for use in re-
moving magnetic foreign bodies from the posteri-
or intraocular segment. The giant magnet, the
permanent hand magnet, the hand electro-mag-
net, and the new Bronson-Magnion instrument5
are among them. The hand electro-magnet is ex-
tremely useful in most clinical circumstances, al-
though extracting a foreign body from the pos-
terior segment via an anterior wound of entry oc-
casionally requires a more powerful magnet. The
giant magnet requires considerably more careful
preoperative and intraoperative planning and
technical execution. Many of the problems at-
tending the use of the hand electro-magnet and
the giant magnet have been eliminated with the
development of the Bronson-Magnion instru-
ment, which is extremely powerful, but which is
about the same in size as the hand electro-mag-
net. Despite considerable cost, the advantages of
this new instrument are great.5

The attractive force of any magnet varies with
the cube of the distance between it and the for-
eign body. Consequently, a foreign body, even if
magnetic, cannot be extracted anteriorly if it lies
too far posteriorly. If it is weakly magnetic or less
than 1 mm. in size, similar difficulty may be en-
countered. The anterior route is dangerous if the
foreign body is greater than 3 mm. in size or if it
is jagged, since intact ocular structures can be ir-
reparably damaged during such an extraction. A
decision to extract a foreign body through the an-
terior segment requires knowledge of the state of
the lens. If the lens is intact and transparent, a

JOURNAL MSMA

posterior route of extraction should invariably be
used, even if the wound of entry is in the limbal
region. On the other hand, if the lens had been
markedly disrupted by the entering foreign body,
there is then much less hesitation towards per-
forming an anterior extraction.

TRAUMATIC CATARACT

In most cases, removal of a traumatic cataract
should not be performed at the time of foreign
body extraction, unless extensive lens trauma has
occurred. An unwary surgeon may be misled by
the presence of inflammatory debris in the pupil-
lary space and anterior chamber, the result of
the original trauma, which may so mimic the
presence of flocculent lens material that only the
test of time will demonstrate the difference be-
tween the two. Consequently, lens extraction,
whether it be intracapsular or extracapsular,
should be deferred. Whenever lens extraction is
performed, it should be recalled at all times that
a penetrating injury through the lens produces
disruption of the anterior hyaloid face and in-
creases the risk of vitreous loss.

In performing magnetic extractions via the an-
terior route, the following technical measures are
useful. As in all cases of magnetic foreign body
extraction, the lid speculum and other instru-
ments should be constructed of nonmagnetic ma-
terials. The bluntest magnet tip consistent with
surgical exposure should be used, since it pro-
vides the strongest force, and the magnet tip
should be brought as close to the foreign body as
possible. Since magnets have much more strength
when cold, intermittent short bursts of current are
more effective than prolonged ones, which unfor-
tunately, heat up the magnet.

After performing customary procedures to soft-
en the eye (such as administration of a preop-
erative carbonic anhydrase inhibitor and a hy-
perosmotic agent), the magnet is directed at the
original wound of entry, and the current is ap-
plied. If the foreign body is magnetic enough or
is close enough to the magnet, there should be
little difficulty in extracting it through the original
wound of entry. Repositioning or excising pro-
lapsed intraocular contents should then be per-
formed in the usual fashion. The wound should
be closed with interrupted sutures and the an-
terior chamber reformed with normal saline solu-
tion.

SECONDARY MANEUVERS

Occasionally, two directions of pull will be re-
quired: the first, in which the magnet is used to
pull the foreign body into the anterior chamber;
and the second, in which the magnet is then

used to extract the foreign body through a sep-
arate, newly created limbal incision. Such a sec-
ondary maneuver is useful when the corneal in-
cision is small or self-sealing. The advantages of
a new limbal incision are that it can be created
under a conjunctival flap and that it can be made
regular without jagged edges, consequently mini-
mizing the danger of uveal tissue incarceration.

If the surgeon elects to remove the foreign
body transsclerally, he must choose between the
pars plana versus the actual site of the foreign
body. If the foreign body lies within the vitreous
chamber, it is frequently best to remove the for-
eign body through the pars plana. If the object is
free-floating in the vitreous and can be easily
moved about, the inferolateral pars plana is the
usual area for extraction, since good surgical ex-
posure is easily achieved in this location. If the
foreign body is fixed in the vitreous chamber
(surrounded by inflammatory or fibrotic materi-
al), the quadrant of the pars plana nearest the
foreign body should be chosen for the extraction.

IMMEDIATE EXTRACTION

If the foreign body lies embedded in the wall
of the eye, extraction should usually be per-
formed immediately over the foreign body itself.
Attempting a magnetic extraction via the pars
plana in such circumstances can result in severe
gashes in the retina as the foreign body is dragged
anteriorly. However, if the foreign body lies em-
bedded in the wall of the eye near the macula,
optic nerve, or posterior ciliary vessels or nerves,
extraction via the pars plana will obviate possible
surgical trauma to those vital stiuctures lying at
the posterior pole of the eye. As in all such intra-
ocular maneuvers, constant monitoring of the for-
eign body and of the retina should be performed
during the actual surgical manipulations, when-
ever possible, with the binocular indirect ophthal-
moscope.

For posterior route magnetic extractions
through the pars plana, the aforementioned pre-
cautions involving preoperative lowering of the
intraocular pressure should be followed. At-
tempts should also be made to minimize pressure
on the globe and to reduce the chances of vitre-
ous loss during the actual extraction of the for-
eign body. A conjunctival peritomy is helpful and
should expose at least a full quadrant of the
globe. Occasionally a more extensive peritomy is
required, but, at any rate, the extraction attempt
should not usually be made through a tiny con-
junctival incision, because suboptimal exposure
increases the hazards of surgery. Sling sutures un-
der the two adjacent rectus muscles are helpful in

APRIL 1970

155

INTRAOCULAR BODIES / Goldberg

manipulating the globe. Occasionally, sling su-
tures under all four rectus muscles are required,
and there should be no hesitation in extending
the peritomy and placing these sutures if expo-
sure is limited or if atraumatic rotation of the
globe is difficult.1

SCLERAL INCISION

A scleral incision calculated to be large enough
to deliver the foreign body should be made to the
external surface of the uveal tract. The site
should be within the confines of the pars plana
(anterior to the ora serrata). Although certain
conventional measurements ostensibly represent
the posterior limit of the pars plana (in milli-
meters from the limbus), the exact location of
the pars plana varies considerably from case to
case. Consequently, one should determine the
location of the pars plana by transillumination.
This can easily be performed at the operating ta-
ble by directing a strong source of fight through
the pupil and noting the demarcation between
the dark ciliary body and the more lightly pig-
mented retinal area. A preplaced suture should
be inserted through the lips of the scleral incision
and the magnet should then be directed at the
slightly gaping wound.

Even if the magnet is activated correctly, the
foreign body may not be removed initially. There
are several explanations for this, including inap-
propriate selection of the magnet tip (particularly
if a curved tip has been used), entanglement of
the foreign body in fibrous and inflammatory de-
bris, or a small or weakly magnetic foreign body.
Extreme patience is often required before extrac-
tion of the foreign body can be accomplished. It
is less important to point the magnet tip directly
at the foreign object than it is to move the short-
est tip that can be used under the conditions of
surgical exposure as close as possible to the for-
eign body. Attempted induction of a point source
of magnetic strength, by holding the magnet
against a metallic instrument (which then is
pointed towards the foreign body), is extremely
inefficient and should not be employed.5

MAGNETIC EXTRACTION

Simultaneous use of the binocular indirect oph-
thalmoscope, whenever possible, provides assur-
ance that the foreign body is being pulled by the
magnet and that it is not entrapped in the retina,
where it can cause large tears. Under most cir-
cumstances, if the foreign body can be attracted
to the sclerotomy, it will cut its own way through

the uveal tract, whereupon the surgeon will per-
ceive an audible click or a tactile impression from
the magnet tip. Occasionally, however, the for- I
eign body is too dull or the magnet too weak,
and a stab incision of the pars plana (through
the sclerotomy) must be performed with a small,
sharp knife. The magnet is then reapplied, and
the foreign body is extracted whilst all traction
and pressure are relieved. The preplaced sclerot-
omy suture is immediately tied. In all such oper-
ations, the original, anterior wound of entry
should have been previously sealed, either spon-
taneously or surgically. The sclerotomy site can
be ringed either pre- or post-extraction with dia-
thermy or cryothermy in order to produce a firm
adhesion of the uveal tract to the sclera.

If a foreign body is embedded in the wall of
the eye and overlies the retina, and if a direct
transcleral magnetic extraction is contemplated,
precise localization is required in order to mini-
mize trauma to the retina. Use of the indirect
ophthalmoscope, the Berman metal locator, and,
occasionally, placement of radiopaque scleral
markers for intraoperative radiologic localizing
procedures contribute in large measure to a suc-
cessful extraction. For a direct posterior, trans-
scleral extraction, a large conjunctival peritomy
and sling sutures under most (or all) of the rec-
tus muscles are required for adequate exposure
and atraumatic manipulation and rotation of the
globe. After precise localization of the foreign
body, a scleral incision is made overlying it to
the external surface of the uveal tract.

Under these conditions, ringing the sclerotomy
site with diathermy or cryothermy is considerably
more important than in pars plana extractions,
since postoperative vitreous traction at the wound
of exit could conceivably produce retinal traction
or hole formation (either at the exit site itself or
at a point 180 degrees across the globe). Since
the precise direction of pull of potential vitreous
traction at the opposite side of the globe cannot
be determined until after the fact, diathermy or
cryothermy to the opposite side of the globe
should not be performed prophylactically. After a
preplaced suture has been inserted in the lips of
the small scleral incision, the magnet is applied;
the foreign body either cuts its own way through
the uveal tract, or is extracted after a uveal stab
incision is made; and the preplaced suture is
closed.

SCLERAL BED

Under most circumstances, this series of ma-
neuvers is sufficient. However, if one anticipates
significant vitreous traction, one may wish to ex-
tract the foreign body through a lamellar scleral

156

JOURNAL MSM A

bed, prepared as in a routine scleral undermining
procedure for repair of retinal detachment. The
diathermized or cryothermized scleral bed is then
buckled inward to reduce traction on the under-
lying retina. Alternatively, one can extract the
foreign body through full-thickness sclera, fol-
lowed by a Custodis-type scleral buckling pro-
cedure, using an exoplant of silicone rubber. The
conjunctival peritomy is then closed, and the pa-
tient is treated in the customary fashion with pu-
pillary dilatation, antibiotics and corticosteroids
as indicated.

In the case of nonmagnetic foreign bodies, sur-
gical maneuvers are considerably more difficult
and potentially more disruptive to the vitreous,
because of the commonly employed intravitreal
manipulations. Direct transscleral extraction
should be performed as in the previously de-
scribed procedure for magnetic extraction. To
minimize vitreous trauma, the sclerotomy must
directly and precisely overlie the foreign body. If
localization has been correct and precise (within
1 mm.), the scleral incision, performed in the
manner already described, will provide direct vis-
ualization of the foreign body. If it lies within the
wall of the eye, it can be simply lifted out of its
resting place with forceps. Closure of the sclerot-
omy, with or without simultaneous scleral buck-
ling, should be completed as detailed above.

USE OF FORCEPS

If the foreign body lies intravitreally, forceps
can be inserted through a large pars plana scle-
rotomy under indirect ophthalmoscopic control.
Since the indirect ophthalmoscope reverses the
image, considerable familiarity with this instru-
ment is a necessary prerequisite to successful in-
travitreal manipulation of forceps. Forceps with
suture-tying platforms or with precisely apposed
flat tips are useful in grasping the foreign body.

After the foreign body is removed, it occasion-
ally will remain attached to a strand of vitreous.
This should be cut flush with the sclerotomy using
sharp scissors in order to prevent unnecessary
tugging on the intraocular vitreous or on the reti-
na. If this simple maneuver is not practiced, one
may experience the unfortunate episode of hav-
ing the foreign body retract inside the eye, due to
the elastic effect of an attached strand of vitreous,
or may subsequently encounter a large retinal
hole.

If the pars plana route is employed, but the
foreign body is invisible due to opaque media or
to other reasons, one has recourse to several tech-
niques. All, however, are hazardous and difficult,
and none guarantees successful extraction of the

foreign body with preservation of good visual
acuity. An ultrasonic probe with a forceps attach-
ment at its tip has been developed for such cases.
An experienced manipulator can perform the ac-
tual extraction in most cases, but only a minority
of patients treated in this way recover good vi-
sion. Subsequent technical developments in this
field may increase the salvage rate.

THORPE ENDOSCOPE

The Thorpe endoscope requires an experi-
enced assistant, as well as an experienced opera-
tor, in order to prevent an excessive length of
this large instrument from being shoved inside
the eye.2 A large pars plana incision, approxi-
mately 9 mm. in length, is required. This instru-
ment does provide illumination within the eye as
well as a chance to grasp the foreign body, but
excessive heating of the vitreous by the illuminat-
ing source can occur with consequent clouding of
the media. Other devices, such as an electrified
forceps (which conveys an audible signal when
its tips close down on a metal foreign body) and
biplane fluoroscopy, have been developed within
recent years in an attempt to improve the cur-
rently unfavorable prognosis of such situations.
Proper evaluation of these instruments requires
widespread use in several medical centers before
unequivocal endorsement of their efficacy can be
offered.

The prognosis for successful extraction de-
pends on two major factors: the magnetic prop-
erties of the foreign body and the ease of visual-
izing it. If the foreign body is both magnetic and
visible, the prognosis is most favorable. If the
foreign body is magnetic but invisible, the prog-
nosis worsens. If the foreign body is visible but
nonmagnetic, the prognosis is even worse; and if
it is both nonmagnetic and invisible, the prog-
nosis is most grave. Even if extraction is per-
formed successfully, however, the overall chance
of recovering good visual acuity is only about 50
per cent.

The occurrence of intraocular foreign bodies,
especially nonmagnetic ones, has not lessened as
the result of technical advances in modern civili-
zation and industry. The intensity of military ac-
tions in various parts of the world contributes, in
large measure, to the frequency of such thera-
peutically difficult clinical situations. Justification
for extensive, additional clinical research in the
management of retained foreign objects is based
on the large number of affected patients, the se-
vere morbidity involved, and the currently rather
gloomy prognosis. ***

4040 North Fairfax Drive (22203)

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157

INTRAOCULAR BODIES / Goldberg

REFERENCES

1. Paton, D., and Goldberg, M. F.: Injuries of the Eye,
the Lids, and the Orbit, Diagnosis and Management,
Philadelphia, W. B. Saunders Company, 1968.

2. Duke-Elder, S.: Textbook of Ophthalmology, vol. 6, In-
juries, London, Henry Kimpton, 1954.

3. Spindell, L.: Localization of Intraocular Foreign Bod-
ies— A Preliminary Report, J. Newark Beth Israel
Hospital, 18: 131-136 (July) 1967.

4. Runyan, T. E., and Penner, R.: Comparison of Local-
ization of Orbital Foreign Bodies by Radiologic and
Ultrasonic Methods, A.M.A. Arch. Ophth. 81:512-
517 (April) 1969.

5. Bronson, N. R.: Practical Characteristics of Ophthal-
mic Magnets, A.M.A. Arch. Ophth. 79:22-27 (Jan.)
1968.

NO PROBLEMS HERE

A band director, going to a Pop Festival, found himself seated
next to a hippie on the bus. “Are you going to the festival?,” he
asked.

“I wouldn’t miss it, man,” was the reply.

“Do you expect they’ll have a drug problem there?” asked the
musician.

“No problem at all,” the hippie said reassuringly, “You’ll be
able to get anything you want.”

158

JOURNAL MSMA

for the debilitated

geriatric patient

TABLETS

high potency B-complex and C
for nutritional support

AVAILABLE ONLY ON Rx

contains water-soluble vitamins only
b.i.d. dosage
good patient acceptance
no odor, and virtually no aftertaste

Each Berocca Tablet contains:

Thiamine mononitrate 15 mg

Riboflavin 15 mg

Pyridoxine HCI 5 mg

Niacinamide 100 mg

Calcium pantothenate 20 mg

Cyanocobalamin 5 meg

Folic acid . 0.5 mg

Ascorbic acid 500 mg

Usual dosage is one tablet b.i.d.

Indications: Nutritional supplementation in conditions in
which water-soluble vitamins are required prophylactically
or therapeutically.

Warning: Not intended for treatment of pernicious anemia
or other primary or secondary anemias. Neurologic involve-
ment may develop or progress, despite temporary remission
of anemia, in patients with pernicious anemia who receive
more than 0.1 mg of folic acid per day and who are in-
adequately treated with vitamin B)2.

Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

dROCHEi:

Roche

LABORATORIES

Division of Hoffmann-La Roche Inc.
Nutley, New Jersey 07110

Radiologic Seminar XCIY
Intravenous Cholangiography

JAMES B. BARLOW, M.D.

Jackson, Mississippi

Intravenous cholangiography has been ac-
cepted as a part of the armamentarium in diag-
nosis of biliary duct as well as gallbladder disease
for more than a decade.

When we started doing intravenous cholangi-
ography we had a heritage of intravenous pye-
lography. Our predecessors had told us to dehy-
drate and fast the patient for about 12 hours be-
fore the study. Since intravenous cholangiogra-
phy was an intravenous procedure, it seemed the
logical thing to do and all of us went down this
road. So for a number of years, we dehydrated
all our patients, starved them, and they came in
miserable, without breakfast, and promptly pro-
ceeded to have a reaction.

Years ago someone from the Mayo Clinic said
that to physicians many reactions are minor; to
patients all reactions are major. This is true,
and this is why one of the first things of interest
that happened in intravenous cholangiography af-
ter many years of experience was a real way of
reducing reactions.

Several months ago, following a report by Dr.
Robert Wise at Lehey Clinic Foundation1 on a
scientific study, done at that institution, we start-
ed doing intravenous cholangiograms with the pa-
tient hydrated and following a light breakfast and
have relatively few reactions and I therefore rec-
ommend this to you.

Since the search for common duct calculi is
the most common indication for intravenous chol-

Sponsored by the Mississippi Radiological Society.

From the Department of Radiology, The Doctors Hos-
pital, Inc.

angiography, it is in this area in which diagnostic
criteria have been most refined. They may be
divided into the direct and indirect approach. We
have all used the direct approach since the pro-
cedure was initiated and in this the calculus is
manifested as a filling defect in the column of
opacified bile.

Again, if we go back to experience with in-
travenous pyelography, a great deal of our diag-
nosis depends upon drainage of the ureter. At
some point thirty or forty minutes after injection,
we decide that if the ureter and upper calyceal
system hasn’t drained properly there must be
some obstruction even though we don’t see a
stone. On intravenous cholangiography the cases
in which calculi are present but impacted in the
distal end of the common bile duct and not visi-
ble serious difficulties arise.2 The size of the duct
alone is of limited value in the diagnosis of par-
tial obstruction. Other criteria were necessary if
the diagnosis of partial obstruction was to be
made with any degree of certainty. Out of this
need grew the time-density retention concept;
first presented in 1956 by Drs. Wise and O’Brian.3
Patients who have no obstruction in the common
duct opacify their ducts rather fast, build to a
peak of a crescendo and then opacification starts
to decrease or drop off in 60 minutes or so. In
patients who have obstruction, the opacification
starts later, tends to reach a plateau, and does
not drop off as rapidly.

On this basis the criteria for diagnosis of ob-
struction have been developed. If the 120 minute
film shows an increase in density, in comparison

160

JOURNAL MSMA

Figure 1. 60 minute film following injection of
Cholografin demonstrating the common duct (arrow).

with the 60 minute film, then there is a partial
obstruction. This is the time-density retention
concept which has stood the test of time, and
has increased diagnostic accuracy.

Figure I is the 60 minute film from a study on
a 49 year old female with right upper quadrant
pain. Figure II is the 120 minute film from the
same study and although no filling defect was
seen there was an increase in density from the
60 minute to the 1 20 minute film and a diagnosis
of partial obstruction was made. At the time of
surgery, there was a small stone impacted in the
very distal segment of the common duct.

SUMMARY

By doing intravenous cholangiograms with the
patient well hydrated and following a light break-
fast. one can greatly decrease the number and

Figure 2. 120 minute film following injection on
the same patient demonstrating increasing opacifi-
cation of the common duct, indicative of an element
of distal obstruction.

severity of reactions to the contrast agent. By
utilizing the rule of thumb formulated by Dr.
Wise at Lehey Clinic, which says that if the 120
minute film shows an increasing density in com-
parison with a 60 minute film there is partial ob-
struction, one can greatly increase diagnostic ac-
curacy.

2969 University Drive (39216)

REFERENCES

1. Johnson, J. H., Jr. and Wise, R. E.: Intravenous
Cholangiography; A Study of Reaction to Iodipamide
Methylglucamine. Lehey Clinic Foundation Building.
13:245-250 (July-Sept. 1964).

2. Wise, Robert E.: Current Concepts of Intravenous
Cholangiography. The Radiological Clinic of North
America, Vol. IV, No. 3:521-523, December, 1966.

3. Wise. R. E. and O’Brian. R. G.: Interpretation of the
Intravenous Cholangiogram. J.A.M.A. 160:810-827
(March 10) 1956.

NEEDLESS WORRY

A couple visiting New Orleans decided to take their 10 year
old son to one of the nightspots. They began to feel a little uneasy
when a stripper appeared clad only in a scanty green and white
ribbon. As the number ended, the boy leaned over and said,
“Mom, did you see those?”

“See what?” asked the mother apprehensively.

“Those colors,” replied the boy. “She was wearing our school
colors!”

APRIL 1970

161

EIGHTY-FIRST
ANNUAL MEETING

of the

MID-SOUTH
MEDICAL ASSOCIATION

(Formerly Mid-South Postgraduate Medical Assembly)

MAY 27, 28, 29, 1970
at the

HOLIDAY INN-RIVERMONT MEMPHIS, TENNESSEE

Outstanding speakers will present half-hour lectures on subjects of interest
to both general practitioner and specialist. A well balanced program is
scheduled. Make your plans to attend NOW!!

CLASS REUNIONS: Class of 1930; Class of 1935 — March, June, Sep-
tember, December; Class of 1939 — December; Class of 1940 — March,
June, September, December; Class of 1945 — March, June, September,
December; Class of 1950 — March, June, September, December; Class
of 1955 — March, June, September; Class of 1956 — June; Class of 1 960 —
March, June, September, December; Class of 1956 — March, June, Sep-
tember, December.

MAKE YOUR PLANS NOW TO ATTEND THE
MID-SOUTH MEDICAL ASSOCIATION
MAY 27, 28, 29, 1970

MEMPHIS TENNESSEE

162

JOURNAL MSMA

102nd Annual Session

Mississippi State Medical Association

May 11-14, 1970
Biloxi

Mississippi’s Gulf Coast, bouncing back as the
Riviera of the South from the ravages of Hur-
ricane Camille, becomes the state’s medical cap-
ital May 11-14 as the 102nd Annual Session of
the association meets at the Hotel Buena Vista.
Six general scientific sessions involving the seven
formal sections, a dozen specialty groups, med-
ical alumni occasions, technical and scientific
exhibits, the House of Delegates, and a host of
fellowship events are slated for the four-day meet.

Dr. James L. Royals of Jackson, association
president, will address the opening meeting of
the House of Delegates on May 1 1 . House Speaker
William E. Lotterhos of Jackson and Vice Speak-
er John B. Howell, Jr., of Canton said that reports
and resolutions will be presented at the opening
meeting. Final actions will come on May 14
when 1970-71 officers are elected.

Dr. Paul B. Brumby of Lexington will be in-
augurated president for the new year during clos-
ing ceremonies on the final day.

Dr. Walter H. Simmons of Jackson said that
the Scientific Assembly will open on Tuesday
morning. May 12, and continue through Thursday
noon. Dr. Simmons heads the group which has
planned and scheduled the general and specialty
session, exhibits, and fellowship occasions.

Principal speaker for the annual session is
Dr. Gerald D. Dorman of New York, president
of the American Medical Association. He is
scheduled to address the opening meeting of the
House of Delegates on May 11, Dr. Royals said.

The Woman's Auxiliary will conduct its 47th
Annual Session concurrently during May 11-13.
also headquartering at the Buena Vista, accord-
ing to Mrs. Louis C. Lehmann of Natchez, state
president. Mrs. Curtis W. Caine of Jackson will
be inaugurated 1970-71 president at the meeting.
General chairman for the ladies’ meet is Mrs.

OFFICIAL CALL

To all members of the Mississippi State

Medical Association:

The 102nd Annual Session of the Missis-
sippi State Medical Association is called to
meet at Biloxi, Mississippi, on Monday,
May 11, 1970, pursuant to Article V of
the Constitution. The House of Delegates
will be convened at 9 o’clock in the morn-
ing at the Hotel Buena Vista on May 11.

The Scientific Assembly, consisting of the
general sessions, will meet during May 12-
14, 1970.

No member or guest will be permitted to
participate in any aspect of the annual ses-
sion until regularly registered.

James L. Royals
President

Walter H. Simmons
Secretary-Treasurer

David L. Clippinger of Hazlehurst, and Mrs.
Steve Sekul of Biloxi is co-chairman.

Medical alumni occasions are set for Monday
and Tuesday evenings, and the annual association
party is the Wednesday feature.

The Buena Vista complex has virtually com-
pleted its rebuilding program following the devas-
tation of Hurricane Camille last August. The
hotel, high-rise motel, and original motel are
operational with only a few rooms lacking in the
motel section around the Olympic pool. The
Buena Vista is accepting reservations subject to
sell-out, after which registrants will be given
priority at the White House and Tradewinds.

APRIL 1970

163

102ND ANNUAL SESSION

STATE OFFICERS 1969-70

Dr. Royals

President
James L. Royals
Jackson

President-Elect
Paul B. Brumby
Lexington

Secretary-Treasurer
Walter H. Simmons
Jackson

Dr. Brumby

Vice Presidents G. Leroy Howell, Starkville

J. Dan Mitchell, Jackson
Jack A. Atktnson, Brookhaven

Speaker of the House

of Delegates William E. Lotterhos, Jackson

Vice Speaker of the

House of Delegates John B. Howell, Jr., Canton

Editor W. Moncure Dabney, Crystal Springs

Associate Editors George H. Martin, Vicksburg

Thomas W. Wesson, Tupelo

Delegates to AMA Howard A. Nelson, Greenwood

G. Swink Hicks, Natchez

BOARD OF TRUSTEES

Mal S. Riddell, Jr., Winona, Chairman
J. T. Davis, Corinth, Vice Chairman
William O. Barnett, Jackson, Secretary
John M. Alford, Jr., Greenwood
James O. Gilmore, Oxford
Guy T. Vise, Meridian
W. E. Moak, Richton
Everett Crawford, Tylertown
James T. Thompson, Moss Point

EXECUTIVE OFFICE

Mr. Rowland B. Kennedy, Executive Secretary
Mr. H. C. Harrell, Executive Assistant

164

JOURNAL MSM A

LIVING PAST PRESIDENTS

A. Street, Vicksburg

1941-42

B. S. Guyton, Oxford

1950-51

James Grant Thompson, Jackson

1951-52

Lamar Arrington, Meridian

1952-53

S. Lamar Bailey, Kosciusko

1955-56

H. C. Ricks, Jackson

1956-57

Howard A. Nelson, Greenwood

1957-58

Guy T. Vise, Meridian

1958-59

Stanley A. Hill, Corinth

1959-60

n

G. Swink Hicks, Natchez

V

1960-61

<«Tl

Lawrence W. Long, Jackson

1961-62

C. P. Crenshaw, Collins

1962-63

Omar Simmons, Newton

1964-65

Everett Crawford, Tylertown

1965-66

James T. Thompson, Moss Point

1966-67

Temple Ainsworth, Jackson

1967-68

Joseph B. Rogers, Oxford

1968-69

APRIL 1970

165

102ND ANNUAL SESSION

ACTIVITIES CALENDAR

REGISTRATION

General registration for the Scientific Assembly and House of
Delegates will be located in the Hurricane Foyer of the Buena
Vista Hotel. No person may be admitted to any activity of the
annual session without first registering. Hours of registration
will be 1:00 to 4:00 p.m. Sunday, May 10; 8:00 a.m. to 5:00
p.m., Monday, Tuesday, and Wednesday, May 11-13; and 8:00
a.m. to 2:00 p.m. Thursday, May 14. The Secretary’s Office
will be located in Rooms 142-144.

SUNDAY, MAY 10, 1970

1:00 p.m. Mississippi Association of Pathologists, Surf Room

MONDAY, MAY 11, 1970

7:

o

o

a.m.

9:

o

o

a.m.

9:

o

o

a.m.

9:

o

o

a.m.

12

:30

p.m.

2:

o

o

p.m.

2

o

o

p.m.

3:

o

o

p.m.

3:

:30

p.m.

3:

:30

p.m.

4

o

o

p.m.

4

o

o

p.m.

5

o

o

p.m.

7

o

o

p.m.

Reference Committees Breakfast, Sun Room
House of Delegates, Fountain Terrace
Mississippi Association of Pathologists, Surf Room
Woman’s Auxiliary Hospitality, Fiesta Room
Mississippi Orthopaedic Society, Glass Room
Reference Committee on Reports of Officers and Board
of Trustees, Fountain Terrace
Reference Committee on Miscellaneous Business, Gold
Room South

Woman’s Auxiliary Finance Committee, Fiesta Room
Reference Committee on Medical Practices, Sun Room
Council on Constitution and By-Laws, Surf Room
Woman’s Auxiliary Preconvention Executive Board
Meeting, Fiesta Room

Ole Miss Medical Alumni Business Meeting, Hurricane
Room E

Auxiliary President’s Reception, Glass Room
Ole Miss Medical Alumni Fellowship Hour, Dinner,
and Dance, Gold Rooms North, Center, and South
and Fountain Terrace

TUESDAY, MAY 12, 1970

8:00 a.m. Scientific Film Session, Hurricane Room E
9:00 a.m. General Scientific Session, Hurricane Room E
12:00 noon Mississippi Ob-Gyn Society, Luncheon, Sun Room

166

JOURNAL MSM A

12:00 noon
12:00 noon
12:00 noon

1 :00 p.m.
1:30 p.m.
2:00 p.m.
5:30 p.m.

6:00 p.m.

Fifty Year Club Luncheon, Surf Room
Woman’s Auxiliary Luncheon, Fountain Terrace
American College of Surgeons Luncheon, Gold Room
Center

Scientific Film Session, Hurricane Room E
American College of Surgeons, Gold Room South
General Scientific Session, Hurricane Room E
Vanderbilt Medical Alumni Fellowship Hour, Glass
Room

Tulane Medical Alumni Fellowship Hour, Sun Room

WEDNESDAY, MAY 13, 1970

7

:30

a.m.

8:

o

o

a.m.

8:

o

o

a.m.

9

o

o

a.m.

9

o

o

a.m.

12:

o

o

noon

12:

o

o

noon

12:

o

o

noon

12:

o

o

noon

1:

o

o

p.m.

1:

: 30

p.m.

2:

o

o

p.m.

2:

:30

p.m.

7:

o

o

p.m.

MSMA Past Presidents’ Breakfast, Fiesta Room
Woman’s Auxiliary Complimentary Continental Break-
fast, Gold Room South
Scientific Film Session, Hurricane Room E
Woman’s Auxiliary General Session, Gold Room South
General Scientific Session, Hurricane Room E
Mississippi Psychiatric Society Luncheon, Sun Room
Mississippi Academy of General Practice Luncheon,
Fountain Terrace

Mississippi Society of Internal Medicine Luncheon,
Fiesta Room

Flying Physicians Association Luncheon, Surf Room
Scientific Film Session, Hurricane Room E
Nominating Committee, Glass Room
General Scientific Session, Hurricane Room E
Woman’s Auxiliary Postconvention Executive Board
Meeting, Gold Room South

Annual Association Party, Gold Rooms North, Center,
and South and Fountain Terrace

THURSDAY, MAY 14. 1970

8:30 a.m. Woman’s Auxiliary Past Presidents’ Breakfast, Fiesta
Room

8:30 a.m. Scientific Film Session, Hurricane Room E
9:30 a.m. General Scientific Session on Pediatrics, Hurricane
Room E

10:00 a.m. General Scientific Session on EENT, Gold Room South
11:30 a.m. Mississippi Radiological Society Luncheon, Glass Room
12:00 noon Mississippi EENT Association Luncheon, Sun Room
1:30 p.m. House of Delegates, Fountain Terrace

APRIL 1970

167

102ND ANNUAL SESSION

EXECUTIVE BUSINESS

Dr. Lotterhos

HOUSE OF DELEGATES
Monday, May 11, 1970
9:00 a.m.

Fountain Terrace
Buena Vista Hotel

William E. Lotterhos
Jackson, Speaker

John B. Howell, Jr.
Canton, Vice Speaker

MEETINGS OF THE HOUSE OF DELEGATES

The opening meeting of the House will be called to order by
the President, and the Speakers will announce the order of
business. An open meeting, to which all members and ladies of
the Auxiliary are invited, will feature addresses by Dr. James L.
Royals, the president, and Dr. Gerald D. Dorman, president
of the American Medical Association. The adjourned meeting
of the House will convene in the Fountain Terrace Room at
1:30 p.m. on May 14.

REFERENCE COMMITTEES

Reports of Officers and Board of Trustees, May 11, Fountain
Terrace, 2:00 p.m.

Miscellaneous Business, May 11, Gold Room South, 2:00 p.m.
Medical Practices, May 11, Sun Room, 3:30 p.m.

Constitution and By-Laws, May 11, Surf Room, 3:30 p.m.
Nominating Committee, May 13, Glass Room, 1:30 p.m.

168

JOURNAL MSM A

THE SCIENTIFIC ASSEMBLY

COUNCIL ON SCIENTIFIC ASSEMBLY
Walter H. Simmons, Chairman

Dr. Simmons

THE COUNCIL

J. Leighton Pettis, Chairman. EENT
James K. Williams, Jr., Secretary

William H. Parker, Chairman, General Practice
W. Johnson Witt, Secretary

Ben P. Folk, Jr., Chairman, Medicine
C. Ralph Daniel, Jr., Secretary

J. Purves McLaurin, Jr., Chairman, Ob-Gyn
Warren Plauche, Secretary

Bill Carr, Jr., Chairman, Pediatrics
William F. Sistrunk, Secretary

Frank J. Morgan, Jr., Chairman. Preventive Medicine
Frank M. Wiygul, Jr., Secretary

W. Coupery Shands, Chairman, Surgery
M. Beckett Howorth, Jr., Secretary

MEDICAL MOTION PICTURES

Calvin T. Hull, Chairman

SCIENTIFIC AND TECHNICAL EXHIBITS

Hurricane Rooms A, B, C, and D
The Beuna Vista Hotel

CONDUCT OF THE SCIENTIFIC ASSEMBLY

The order of exercise, papers, and discussion as set forth in

the official program shall be followed until completion. All

papers read before the association shall become its property.

Each paper must be read by its author and deposited with the

Secretary (or Chairman) when read.

1970

169

102ND ANNUAL SESSION

THE SCIENTIFIC EXHIBIT

Physicians, foundations, organizations, and major medical in-
stitutions will present the Scientific Exhibit. Physician-members
of the Mississippi State Medical Association are eligible for the
Aesculapius Award, an honorarium cash purse, given for ex-
cellence of presentation, quality of content, and originality.
Others may not participate in this competition, but they are
eligible for the association’s Scientific Achievement Award, a
sculptured bronze medallion, in recognition of the best presen-
tation by a nonmember. The Scientific Exhibit is located in
Hurricane Room D between the Technical Exhibit and the
principal meeting auditorium.

EXHIBITS AND AUTHORS

“Nuclear Medicine in a General Hospital”

Ottis G. Ball, Elmer J. Harris, Robert P. Henderson, and
James M. Packer, Radiological Group, Mississippi Baptist
Hospital, Jackson

“The Children’s Hospital — University Medical Center”

Blair E. Batson, Professor and Chairman, Department of
Pediatrics, Jackson

“To Conquer Cervix Cancer”

Richard C. Boronow, Robert Smith, Durward Blakey,
Kenneth Pittman, Carl Evers, Forrest Bratley, Guy Gilles-
pie, Hardy Woodbridge, Frank Wiygul, and Walter H.
Simmons, Jackson

“Cytopathology of the Female Genital Tract”

Forrest G. Bratley, William P. Featherston, Kenneth M.
Heard, and Louis Schiesari, associates of the Central Cyto-
pathology Laboratory, Jackson

“Diagnostic Peritoneal Irrigation: A Simple and Reliable Tech-
nique”

Major Joseph M. Civetta, USAF, MC, and Major William
T. Ferguson, USAF, MC, USAF Medical Center, Keesler
AFB

“Intravenous Regional Anesthesia, a Valuable Adjunct to
Surgery”

R. J. Field, Jr., Centreville
“Cosmesis and Camouflage”

James H. Hendrix, Jr., H. C. Ethridge, and W. Douglas
Godfrey, Jackson

170

JOURNAL MSMA

“Total Intravenous Nutrition”

Richard C. Miller, Mart McMullan, and Pervie Simpson,
Division of Pediatric Surgery, University Medical Center,
Jackson

"The Evaluation of the Dizzy Patient”

James T. Robertson and Coyle Shea, Memphis

“Intracavitary Treatment of Malignant Brain Tumors”

Alex Sanford, Department of Neurosurgery, University
Medical Center, Jackson

“Complications of Hair Transplantation”

Dowling B. Stough, III, Hot Springs

“Coronary Arteriosclerosis: Surgical Treatment”

Charles W. Pearce and White E. Gibson, III, New Or-
leans

“Systemic Clues to Occult Cancer”

James P. Spell, Jackson

“Surgical Management of Coronary Occlusion”

Hilary H. Timmis, James D. Hardy, Patrick H. Lehan,
and Kenneth R. Bennett, Departments of Medicine and
Surgery, University Medical Center, Jackson

“Surgical Aspects of Cerebrovascular Disease”

Thomas L. Kilgore, J. Harvey Johnston, George E. Twente,
W. Coupery Shands, James C. Griffin, Jackson

“Coronary Heart Disease”

Thomas L. Kilgore, J. Harvey Johnston, George E. Twente,
W. Coupery Shands, James C. Griffin, Jackson

OLD MISS MEDICAL ALUMNI

University of Mississippi Medical Alumni will meet on Mon-
day, May 11. Alumni officials will conduct registration in the
general convention registration area at the Buena Vista where
tickets will be available for the evening party. A general busi-
ness meeting will be conducted at 4:00 p.m. in Hurricane Room
E. The fellowship hour, dinner, and dance will be conducted in
the Gold Rooms North, Center, and South and on the Fountain
Terrace beginning at 7:00 p.m., Dr. Hector S. Howard, Mem-
phis, president, presiding. Dr. Paul H. Moore of Pascagoula
is president-elect, Dr. James S. Fisckerly of Biloxi is program
chairman, and Mr. Charles William Price of Jackson is secre-
tary. Further details and advance tickets may be secured from
Mr. Price at the University Medical Center, Jackson.

APRIL 1970

171

102ND ANNUAL SESSION

THE TECHNICAL EXHIBIT

The Mississippi State Medical Association presents with pride
the 1970 Technical Exhibit. Established firms engaged in the
manufacture and distribution of pharmaceuticals, supplies,
equipment, and in providing varied services will present exhibits.
Visit each exhibit often and discuss products and services with
the Professional Service Representatives. Only registered mem-
bers and guests are admitted. The Technical Exhibit is located
in the Hurricane Room, the Buena Vista Hotel.

EXHIBITORS BOOTH

Abbott Laboratories, North Chicago, 111. 9

Ayerst Laboratories, New York, N. Y 32

Bedsole Surgical Supply Co., Inc., Mobile, Ala

Bristol Laboratories, Syracuse, N. Y.

Carnation Company, Los Angeles, Calif.

Carnrick Laboratories, Cedar Knolls, N. J

CIBA Pharmaceutical Co., Summit, N. J.

Coca-Cola USA, Atlanta, Ga

The Emko Company, St. Louis, Mo

Financial Service Corporation, Brookhaven, Miss.

Imperial Fashions, Los Angeles, Calif

Kay Surgical, Inc., Jackson, Miss.

Lanier Company, Jackson, Miss

Massachusetts Mutual Life Insurance Co., Jackson, Miss.

McNees Medical Supply Company, Jackson, Miss

Mead Johnson Laboratories, Evansville, Ind

Merck Sharp and Dohme, West Point, Penn

19

34

43

41
11
12

42

4
45
33
30

7

10

1

5

172

JOURNAL MSM A

31

Merrill Lynch, Pierce, Fenner and Smith, Inc., Jackson, Miss.

Meyer Laboratories, Inc., Fort Lauderdale, Fla. 18

Mississippi Hospital and Medical Service, Jackson, Miss 44

Parke, Davis and Company, Detroit, Mich 2

Wm. P. Poythress and Co., Inc., Richmond, Va 20

A. H. Robins Company, Richmond, Va 24

William H. Rorer, Inc., Fort Washington, Penn 6

Sandoz Pharmaceuticals, Hanover, N. J 35

W. B. Saunders Company, Philadelphia, Penn 21

Schering Laboratories, Union, N. J 8

Smith, Miller and Patch, Inc., New York, N. Y 3

St. Paul Insurance Companies, St. Paul, Minn 17

Stuart Pharmaceuticals, Pasadena, Calif 22

Travelers Insurance Co., Jackson, Miss 23

The Upjohn Company, Memphis, Tenn. 29

SCIENTIFIC GRANTS

Geigy Pharmaceuticals, Ardsley, N. Y.

SEMED Pharmaceuticals, San Francisco, Calif.

Smith, Kline and French Laboratories, Philadelphia, Penn.

Eli Lilly and Company, Indianapolis, Ind.

REGISTRATION FOR EXHIBIT PRIZES

Visit the Technical Exhibits often and qualify for the drawing
of attractive prizes. Obtain necessary initials as you visit each
booth. Deposit cards at Registration not later than 12:30 p.m.,
Thursday, May 14.

APRIL 1970

173

102ND ANNUAL SESSION

SCIENTIFIC PROGRAM

Tuesday, May 12, 1970
Hurricane Room E
Beginning at 9:00 a.m.

W. Coupery Shands, Jackson
Chairman

M. Beckett Howorth, Jr., Oxford
Secretary

Intestinal Obstruction in the Newborn
Richard C. Miller, Jackson

The Present Status of Myocardial Revascularization
John L. Ochsner, New Orleans

The Surgical Aspects of the Thymus

Philip E. Bernatz, Rochester, Minnesota

Amputations in Patients with Peripheral Vascular Disease
Richard Warren, Boston

Dr. Shands

SCIENTIFIC PROGRAM

Tuesday, May 12, 1970
Hurricane Room E
Beginning at 2:00 p.m.

J. Purves McLaurin, Jr., Oxford
Chairman

Warren C. Plauche, Biloxi
Secretary

Family Planning in Mississippi, Present and Near Future
George R. Huggins, Jackson

Diagnosis and Management of Secondary Amenorrhea
Donald A. Goss, Nashville

Maternal Mortality Related to Anesthesia, 1957-1967, State
of Mississippi

Donald M. Sherline, Jackson

The Adolescent’s Social and Sexual Development in the
United States — A Review of Changing Concepts
Kermit E. Krantz, Kansas City

Complications Relative to the Use of the Birth Control
Pill

George Ball, Jackson, Moderator

Panel: Drs. Goss, Krantz, Herbert G. Langford of Jackson
and J. Leighton Pettis of Tupelo

Dr. McLaurin

174

JOURNAL MSMA

SCIENTIFIC PROGRAM

Wednesday, May 13, 1970
Hurricane Room E
Beginning at 9:00 a.m.

Frank J. Morgan, Jr., Jackson
Chairman

Frank M. Wiygul, Jr., Jackson
Secretary

Dr. Morgan

Community Mental Health Centers
Mary Alice Lee, Jackson

Youth and Drugs

Judge Carl E. Guernsey, Jackson

SCIENTIFIC PROGRAM

Wednesday, May 13, 1970
Hurricane Room E
Beginning at 10:00 a.m.

William H. Parker, Heidelberg
Chairman

W. Johnson Witt, Jackson
Secretary

Dr. Parker

The Fat Diabetic

Buris R. Boshell, Birmingham

Pitfalls of Eye Care in Industrial Practice
James K. Williams, Jr., Pascagoula

Industrial Back Injuries

John G. Caden, Jr., and William C. Warner, Jackson

Fingertip Injuries and Fractures of the Hand
Claude S. Williams, New Orleans

APRIL 1970

175

102ND ANNUAL SESSION

SCIENTIFIC PROGRAM

Wednesday, May 13, 1970
Hurricane Room E
Beginning at 2:00 p.m.

Ben P. Folk, Jr., Jackson
Chairman

C. Ralph Daniel, Jr., Jackson
Secretary

Dr. Folk

Certain Current Concepts of Immunological Diseases
Frederic C. McDuffie, Rochester, Minnesota

Meningococcal Septicemia
Robert E. Blount, Jackson

Current Laboratory Evaluation of Lipid Disorders
William B. Wilson, Jackson

Hereditary Enzymatic Defects of the Red Cell — Clinical
Implications

Francis S. Morrison, Jackson

SCIENTIFIC PROGRAM

Thursday, May 14, 1970
Hurricane Room E
Beginning at 9:30 a.m.

Bill Carr, Jr., Gulfport
Chairman

William F. Sistrunk, Jackson
Secretary

Current Immunization Trends and Indications for the Newer
Live Virus Vaccines

Mark A. Belsey, New Orleans

Pediatric Hematological Problems
Jeanette Pullen, Jackson

Recent Trends in Newborn Nursery Care, Including Photo-
therapy of Jaundice
Alfred W. Brann, Jackson

Dr. Carr

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JOURNAL MSM A

SCIENTIFIC PROGRAM

Thursday, May 14, 1970
Gold Room South
Beginning at 10:00 a.m.

J. Leighton Pettis, Tupelo
Chairman

James K. Williams, Jr., Pascagoula
Secretary

Cerebellopontine Angle Tumors — Early Diagnosis and Sur-
gical Treatment

James T. Robertson and Coyle Shea, Memphis

Diabetic Retinopathy
David Meyer. Memphis

GOLF TOURNAMENT

The annual association golf tournament will be conducted at
the Sunkist Country Club on Wednesday, May 13, Dr. A. V.
Hays, Gulfport, chairman. The $12 entrance fee includes one
green fee ticket and two 19th Hole refreshment tickets. Awards
to winners will be made at 5:00 p.m. in the clubhouse. Handi-
caps are not needed, the two flights being divided among those
over and under 55 years of age. Advance registration is en-
couraged, sending name and fee to Dr. Hays at the ENT Hos-
pital, 13th and 31st Avenue, Gulfport 39501. Tuesday rounds
are acceptable for the single round 18 hole play. Pre-registrants
may pick up tickets at the pro shop; others at General Registra-
tion at the Buena Vista Hotel.

ANNUAL ASSOCIATION PARTY

Fun, food, fellowship, and frolic highlight Wednesday evening,
May 13, at the annual association, no-theme party in the Gold
Rooms North, Center, South and the Fountain Terrace. Fellow-
ship begins at 7:00 p.m., continuing through dinner and dancing
with Ed Butler and his Orchestra. Tickets will be available at
General Registration in the Hurricane Room Foyer.

177

APRIL 1970

102ND ANNUAL SESSION

VISITING ESSAYISTS

Mark A. Belsey, M.D., New Orleans,
Louisiana. Acting Chairman of Epidemiol-
ogy, Tulane University. Medical Education,
New York Medical College, 1960. Diplo-
mate, American Board of Pediatrics.

Dr. Belsey

Philip E. Bernatz, M.D., Rochester, Min-
nesota. Associate Professor of Surgery,
Mayo Graduate School of Medicine, Uni-
versity of Minnesota. Medical Education,
State University of Iowa, 1944. Diplomate,
American Boards of Surgery and Thoracic
Surgery.

Dr. Bernatz

Dr. Boshell

Buris R. Boshell, M.D., Birmingham, Ala-
bama. Professor of Medicine, Medical Col-
lege of Alabama. Medical Education, Har-
vard Medical School, 1953. Diplomate,
American Board of Internal Medicine.

Gerald D. Dorman, M.D., New York.

President, American Medical Association.

Medical Education, Columbia University
College of Physicians and Surgeons, 1929.

Diplomate, American Board of Preventive
Medicine.

Dr. Dorman

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JOURNAL MSMA

Donald A. Goss, M.D., Nashville, Tennes-
see. Professor and Chairman of Obstetrics
and Gynecology, Vanderbilt University.
Medical Education, Harvard Medical School,
1959. Diplomate, American Board of Ob-
stetrics and Gynecology.

Dr. Goss

Judge Guernsey

Hon. Carl E. Guernsey, Jackson. Profes-
sional Education: Millsaps College, B.A.;
University of Mississippi School of Law,
LL.B. Presiding Judge, Hinds County Court
and Youth Court.

Kermit E. Krantz, M.D., Kansas City,
Kansas. Professor and Chairman of Ob-
stetrics and Gynecology, University of Kan-
sas. Medical Education, Northwestern Uni-
versity Medical School, 1948. Diplomate,
American Board of Obstetrics and Gynecol-
ogy-

Frederic C. McDuffie, M.D., Rochester,
Minnesota. Assistant Professor of Medicine,
University of Minnesota. Medical Education,
Harvard Medical School, 1951. Diplomate,
American Board of Internal Medicine.

Dr. McDuffie

Dr. Krantz

APRIL 1970

179

102ND ANNUAL SESSION

VISITING ESSAYIST

Dr. Meyer

David Meyer, M.D., Memphis, Tennessee.
Instructor, Department of Ophthalmology,
University of Tennessee. Medical Educa-
tion, University of Tennessee, 1962. Diplo-
mate, American Board of Ophthalmology.

John L. Ochsner, M.D., New Orleans,
Louisiana. Clinical Associate Professor, Tu-
lane University, and Chairman of Surgery,
Ochsner Clinic. Medical Education, Tulane
University, 1952. Diplomate, American
Boards of Surgery and Thoracic Surgery.

Dr. Ochsner

Dr. Warren

Richard Warren, M.D., Boston, Massachu-
setts. Professor of Surgery, Harvard Medical
School. Medical Education, Harvard Med-
ical School, 1934. Diplomate, American
Board of Surgery.

Claude S. Williams, M.D., New Orleans,
Louisiana. Instructor, Tulane University
School of Medicine. Medical Education,
Tulane University, 1959. Diplomate, Amer-
ican Board of Orthopaedic Surgery.

Dr. Williams

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JOURNAL MSM A

WOMAN’S AUXILIARY TO THE
MISSISSIPPI STATE MEDICAL ASSOCIATION

47th Annual Session
Buena Vista Hotel
May 11-13, 1970

Mrs. Lehmann

OFFICERS

Mrs. Louis C. Lehmann
Natchez
President

Mrs. Curtis W. Caine
Jackson
President-elect

Mrs. Caine

ANNUAL SESSION CHAIRMEN

Mrs. David L. Clippinger
Hazlehurst
General Chairman

Mrs. Steve Sekul
Biloxi

Co-Chairman

Mrs. G. Swink Hicks
Mrs. Sidney O. Graves, Jr.
Natchez
Luncheon

Mrs. Nicholas DiSanti
Pascagoula
Registration

Mrs. H. Lowry Rush, Jr.
Meridian
Publicity

Mrs. James T. Thompson
Moss Point

VIP and Transportation

AUXILIARY

Sunday, May 10, 1970
2:00 p.m. Registration, Buena Vista Lobby

1 8 1

APRIL 1970

102ND ANNUAL SESSION

Monday, May 11, 1970

9:00 a.m. Registration, Lobby

9:00 a.m. Auxiliary Hospitality, Fiesta Room

3:00 p.m. Finance Committee, Mrs. A. T. Tatum, Fiesta Room

4:00 p.m. Preconvention Executive Board Meeting, Mrs. Louis
C. Lehmann, Presiding, Fiesta Room

5:00 p.m. President’s Reception, Glass Room, for the Executive
Board and Auxiliary members arriving early

Tuesday, May 12, 1970

9:00 a.m. Registration, Lobby

12:00 noon Luncheon, Fountain Terrace
Adams County Auxiliary
Mrs. Kurtz B. Stowers, President
Mrs. G. Swink Hicks and Mrs. Sidney O. Graves,
Jr., Luncheon Chairmen
Theme: “Happiness is . . .”

Mrs. Louis C. Lehmann, Presiding
Invocation

Introduction of Guests
Guest Speaker

Mrs. G. Prentiss Lee, Portland, Ore.

First Vice President, Woman’s Auxiliary to the
American Medical Association

3:00 p.m. Optional Tour, Beauvoir

Admission $.75 per person

Meeting in Lobby at 2:30 p.m. for Transportation

Wednesday, May 13, 1970
8:00 a.m. Registration, Lobby

8:00 a.m. Complimentary Continental Breakfast for Auxiliary
Members, Gold Room South

9:00 a.m. General Session, Gold Room South

Mrs. Louis C. Lehmann, Presiding
Invocation
Auxiliary Pledge

Mrs. Clarence H. Webb, Jr., Jackson
Welcome

Mrs. Maurice A. Taquino, Ocean Springs

I 82

JOURNAL MSM A

Response

Mrs. Jack A. Stokes, Pontotoc
Introductions
Greetings

James L. Royals, M.D., Jackson
President, MSMA
Paul B. Brumby, M.D., Lexington
President-elect, MSMA

Credentials and Registration

Mrs. Nicholas DiSanti, Pascagoula

Roll Call

Minutes

President’s Report

Mrs. Louis C. Lehmann, Natchez

Treasurer’s Report

AMA-ERF Report

Mrs. A. E. Brown, Columbus

Finance Report

Mrs. A. T. Tatum, Hattiesburg

Appointment of Delegates to AMA Auxiliary

Unfinished Business

New Business

Memorial Service

Mrs. James W. Allison, Jr., Vicksburg

Report of the Nominating Committee
Mrs. Paul B. Brumby, Lexington

Election of Officers

Installation of Officers

Courtesy Resolution

Mrs. James V. Ferguson, Jr., Greenwood
Adjournment

2:30 p.m. Postconvention Executive Board Meeting
Mrs. Curtis W. Caine, Presiding
Gold Room South

7:00 p.m. Annual Mississippi State Medical Association Party

Fountain Terrace and Gold Rooms, North Center,
and South

Thursday, May 14, 1970

8:30 a.m. Past Presidents’ Breakfast, Fiesta Room
Mrs. Paul B. Brumby, Presiding

APRIL 1970

183

102ND ANNUAL SESSION

AMERICAN COLLEGE OF SURGEONS,
MISSISSIPPI CHAPTER

Buena Vista Hotel
Tuesday, May 12, 1970

Richard F. Riley, Meridian, President

Dawson B. Conerly, Jr., Hattiesburg, President-elect

Albert L. Meena, Jackson, Secretary

12:00 noon Luncheon and Business Meeting, Gold Room Center
Members and Guests

1:30 p.m. Scientific Program, Gold Room South
All MSMA Members Are Invited
Treatment of Venous Thromboembolism
Richard Warren, Boston

2:15 p.m. The Surgical Management of Functional Dis-
eases of the Esophagus

Philip E. Bernatz, Rochester, Minnesota

3:00 p.m. Problem Cases in Surgery

Frank H. Tucker, Jr., Meridian
Benton M. Hilbun, Tupelo
Richard C. Boronow, Jackson
T. E. Ross, III, Hattiesburg

MISSISSIPPI SOCIETY OF ANESTHESIOLOGISTS

The Mississippi Association of Anesthesiologists will meet at
the University Medical Center, Jackson, on Sunday, May 10.
The guest speaker will be Dr. Richard C. Miller of Jackson,
UMC Assistant Professor of Surgery (Pediatric Surgery), who
will speak on “Fluid Balance in Pediatric Surgical Patients.”
Society officers are Drs. Leonard W. Fabian of Jackson, presi-
dent; Robert B. Thompson of Jackson, president-elect; and
Richard C. Snow of Jackson, secretary.

MISSISSIPPI ASSOCIATION OF PATHOLOGISTS

Members of the Mississippi Association of Pathologists will meet
on Sunday and Monday, May 10 and 11. Activities will begin
at 1:00 p.m. in the Surf Room on Sunday and continue on Mon-
day with a further session at 9:00 a.m., also in the Surf Room.
Dr. George M. Sturgis of Jackson is president, and Dr. William
V. Hare of Jackson is secretary.

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JOURNAL MSMA

REFERENCE COMMITTEES BREAKFAST

Members of all Reference Committees of the House of Delegates
will meet for breakfast on Monday morning. May 11, in the
Sun Room at 7:00 a.m. Hosts are Drs. William E. Lotterhos
of Jackson, Speaker of the House of Delegates, and John B.
Howell, Jr., of Canton, Vice Speaker. The meeting is important
in that Reference Committee members will be oriented as to
duties and the conduct of hearings later in the day.

MISSISSIPPI ORTHOPAEDIC SOCIETY

A luncheon meeting of the Mississippi Orthopaedic Society will
be conducted in the Glass Room on Monday, May 11, at 12:30
p.m. A program will follow the luncheon. Officers are Drs. Wil-
liam B. Thompson of Jackson, president; Daniel J. Enger of
Pascagoula, president-elect; James O. Manning of Jackson, vice
president; and Louis A. Farber of Jackson, secretary.

FIFTY YEAR CLUB

Members of the Mississippi State Medical Association's Fifty
Year Club will be honored at a luncheon on Tuesday, May 12,
in the Surf Room. Dr. Mai S. Riddell, Jr., of Winona, chairman
of the Board of Trustees, will preside, and Mrs. Cindy Sanders
of the MSMA staff is secretary.

MISSISSIPPI OB-GYN SOCIETY

The Mississippi Ob-Gyn Society will conduct a luncheon meet-
ing on Tuesday, May 12, in the Sun Room at 12:00 o’clock
noon. Officers of the society are Drs. William S. Cook of Jack-
son, president and meeting chairman; William R. Raulston of
Hattiesburg, president-elect; and George Ball of Jackson, sec-
retary.

VANDERBILT MEDICAL ALUMNI

Vanderbilt Medical Alumni will meet at a reception on Tues-
day, May 12 from 5:30 until 7:00 in the evening in the Glass
Room. Hosts for the reception are Drs. Archie C. Hewes and
Edward C. Hamilton of Gulfport. The guest of honor will be
Dr. John L. Shapiro, professor and chairman of the Department
of Pathology. Arrangements are under the charge of Mrs. Sue
F. Segrest, director of Medical Alumni and Development Affairs.

TULANE MEDICAL ALUMNI

Medical Alumni of the Tulane University will enjoy a fellow-
ship hour from 6:00 until 8:00 on Tuesday evening. May 12,
in the Sun Room. Dr. Maxwell E. Lapham, Executive Secretary
of the Medical Alumni Association, and Miss Rose B. Koppel
of his office are in charge of arrangements.

p:

CD

APRIL 1970

185

102ND ANNUAL SESSION

MSMA PAST PRESIDENTS’ BREAKFAST

Past Presidents of the Mississippi State Medical Association
will enjoy a breakfast meeting on Wednesday morning. May 13,
in the Fiesta Room at 7:30 a.m. Dr. Joseph B. Rogers of Oxford
is host.

MAGP LUNCHEON

The Mississippi Academy of General Practice will sponsor a
luncheon at 12:00 o’clock noon on Wednesday, May 13, on
the Fountain Terrace. Officers are Drs. Walter W. Crawford of
Tylertown, president; William H. Parker of Heidelberg, presi-
dent-elect; John G. Atwood of Meridian, secretary-treasurer;
and Miss Louise Lacey of Jackson, executive secretary. A spe-
cial guest speaker will be featured.

FLYING PHYSICIANS ASSOCIATION

The Flying Physicians Association and nonmembers interested
in private aviation will enjoy a luncheon on Wednesday, May 13,
in the Surf Room at 12 o’clock noon. The Mississippi president
is Dr. Jim C. Barnett of Brookhaven.

MISSISSIPPI SOCIETY OF INTERNAL MEDICINE

A luncheon meeting of the Mississippi Society of Internal Med-
icine will be held on Wednesday, May 13, at 12:00 o’clock noon
in the Fiesta Room. Officers of the society are Drs. Ben P. Folk,
Jr., of Jackson, president and meeting chairman; William C.
Kellum of Tupelo, president-elect; and S. H. McDonnieal, Jr.,
of Jackson, secretary.

MISSISSIPPI PSYCHIATRIC ASSOCIATION

Members of the Mississippi Psychiatric Association will meet
in the Sun Room on Wednesday, May 13, for a luncheon and
special program at 12:15 p.m. Officers are Drs. George C.
Hamilton, Jr., of Jackson, president; William H. C. Dudley of
Whitfield, president-elect and meeting chairman; and William
C. McQuinn of Jackson, secretary.

MISSISSIPPI RADIOLOGICAL SOCIETY

The Mississippi Radiological Society will sponsor a luncheon
meeting on Thursday, May 14, in the Glass Room, beginning
at 11:30 a.m. Officers of the society are Drs. Clyde Smith of
Greenwood, president; James B. Barlow of Jackson, president-
elect; and Ottis G. Ball of Jackson, secretary.

MISSISSIPPI EENT ASSOCIATION

The Mississippi Eye, Ear, Nose, and Throat Association will
conduct a business meeting and luncheon on Thursday, May 14,
in the Sun Room at 12:00 o’clock noon. Officers are Drs.
Samuel B. Johnson of Jackson, president and meeting chairman;
Chester W. Masterson of Vicksburg, president-elect; and Ben
McCarty, Jr., of Jackson, secretary.

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JOURNAL MSMA

Handbook of the
House of Delegates

Mississippi State Medical Association
102nd Annual Session, Biloxi
May 11-14, 1970

SUPPLEMENTAL REPORT “A"
OF THE SECRETARY-TREASURER

Vacancies in Elected Offices. Effective May
14, 1970, there will occur 25 vacancies in elected
offices in the association by reason of expiration
of prescribed terms of service. In accordance
with applicable portions of the By-Laws, the
Nominating Committee will be asked to deliber-
ate, consult with colleagues, and make nomina-
tions to the House of Delegates for consideration
and voting to elect successors or to re-elect in-
cumbents.

Eligibility. To be nominated for office in the
association, a nominee must have been a mem-
ber for two years and must have attended two
of the past three annual sessions, including the
present one. A member may not serve more
than three consecutive terms as a member of the
Board of Trustees or a council. No incumbent is
ineligible for re-election by reason of three terms
of service.

Vacancies for Nomination. Following is a list-
ing of vacancies which will occur during the
102nd Annual Session as well as requirements
for nominations and identity of incumbents:

President-elect

Nominate three, no two of whom may be from
the same county, elect one.

Vice Presidents

Nominate three for the Northern Area, three
for the Mid-State Area, and three for the South-
ern Area. Elect one for each area.

Secretary-T reasurer

Term 1970-73. Nominate three, elect one. In-
cumbent: Walter H. Simmons, Jackson.

HANDBOOK INFORMATION

The Speaker and Vice Speaker of the
House of Delegates herewith present for the
information of all members those reports
and resolutions as have been received for
publication in advance of the 102nd Annual
Session. It is the intent of this advance publi-
cation to inform the membership and to af-
ford all concerned the opportunity to confer
with delegates over any aspect of the reports
and resolutions.

No report or resolution herein becomes
official or a statement of policy until formal-
ly presented to the House of Delegates and
acted upon at the annual session.

William E. Lotterhos
Speaker

John B. Howell, Jr.

Vice Speaker

Speaker of the House of Delegates

Term 1970-73. Nominate three, elect one. In-
cumbent: William E. Lotterhos, Jackson.

Vice Speaker of the House of Delegates

Term 1970-73. Nominate three, elect one. In-
cumbent: John B. Howell, Jr., Canton.

Associate Editor

Term 1970-72. Nominate two, elect one. In-
cumbent: George H. Martin, Vicksburg.

APRIL 1970

187

HOUSE OF DELEGATES / Continued

Delegate to AM A

Term Jan. 1, 1971 -Dec. 31, 1972. Nominate
two, elect one. Incumbent: Howard A. Nelson,
Greenwood.

Alternate Delegate to AM A

Term Jan. 1, 1971-Dec. 31, 1972. Nominate
two, elect one. Incumbent: Stanley A. Hill,
Corinth.

Board of Trustees, Districts 1 , 2, and 3

Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents: John
M. Alford, Greenwood, District 1; James O. Gil-
more, Oxford, District 2; and J. T. Davis, Cor-
inth, District 3.

Council on Budget and Finance

Term 1970-73. Nominate two, elect one. In-
cumbent: Daniel L. Hollis, Biloxi.

Council on Constitution and By-Laws

Term 1970-73. Nominate two, elect one. In-
cumbent: Arthur E. Brown, Columbus.

Judicial Council, Districts 7 , 8, and 9

Terms 1970-73. Nominate two for each district,
elect one for each district. Incumbents: J. P. Cul-
pepper, Jr., Hattiesburg, District 7; Leo J. Scan-
lon, Jr., Natchez, District 8; and James T. Thomp-
son, Moss Point, District 9.

Council on Legislation, Districts 4, 5, and 6

Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents:
Paul B. Brumby, Lexington, District 4; George
E. Twente, Jackson, District 5; and Guy T. Vise,
Meridian, District 6.

Council on Medical Education

Term 1970-73. Nominate two, elect one. In-
cumbent: Frederick E. Tatum, Hattiesburg.

Council on Medical Service, Districts 7 , 8, and 9
Terms 1970-73. Nominate two for each dis-
trict, elect one for each district. Incumbents:
Charles R. Jenkins, Laurel, District 7; Jack A. At-
kinson, Brookhaven, District 8; and Bedford F.
Floyd, Gulfport, District 9.

Mississippi State Board of Health

No vacancies will occur in 1970 among phy-
sician-members.

REPORT OF THE DELEGATES TO AMA

P

Reporting Format. Your Delegates to the
American Medical Association continue to limit
their joint report to this House of Delegates to P
key policy actions at the annual and clinical con-
ventions. Because of excellent and detailed re- to
porting in the American Medical News and
Journal AMA of scientific and subsidiary activ-
ities, these aspects would only be needless repe-
titions and duplications.

Dr. G. Swink Hicks of Natchez completed his
hist full term of two years in 1969 and began
serving his second term to which he was re-elect- . t,
ed in 1969 on Jan. 1, 1970. The senior Delegate,
Dr. Howard A. Nelson of Greenwood, will com-
plete his second full term during the current year.
Our able Alternate Delegates are Drs. Stanley A. 1
Hill of Corinth and Joseph B. Rogers of Oxford.

The present reporting covers the 1 1 8th An-
nual Convention at New York, July 13-17, and
the 23rd Clinical Convention at Denver, Nov.
30-Dec. 3, both 1969. We are grateful for the
attendance, participation, and support at these
meetings of our president. Dr. Royals, and our
president-elect, Dr. Brumby. Many other Missis-
sippi physicians attended and participated in
these conventions, contributing to scientific and
business activities.

New York Annual Convention. The House of
Delegates considered 59 reports and 137 resolu-
tions, meeting in formal session about 16 hours
over four days. Distinguished speakers included
Vice President Agnew and Dr. Roger O. Ege-
berg, Assistant Secretary of HEW for Health and
Scientific Affairs.

Major items of business and policy included
peer review, health care of the poor, medical
care as a matter of right. Medicare and Medicaid,
relations with hospitals, laboratory advertising
and billing, sex education, and internal organi-
zation and finances of AMA.

The House moved decisively on peer review,
encouraging full and complete participation and
implementation at all levels of medical organiza-
tion. The House stated that it “knows of no
greater challenge facing the profession today
than to secure universal acceptance and applica-
tion of the peer review concept. . . .” The action
made it clear that should medicine fail in meet-
ing this challenge, the task will be done for us
and not on our terms.

In this same connection, the delegates recog-
nized the physician’s influence on the cost of
care, stating that “the doctor has a significant
and responsible role in any organized effort to
control health care expenditures.” With specific

188

JOURNAL MSM A

reference to Medicare and Medicaid, the House
took four major actions:

— Expanded peer review at component society
level to reduce hospital and extended care fa-
cility stay and to expand ambulatory care.

— Eradication by the profession of isolated
abuses by physicians.

— Promotion of innovative health service de-
livery systems for low income communities.

— Preservation of care quality in the face of
cost containment measures.

But in the matter of Social Security Adminis-
tration fee freezes, the House said that the set-
ting of “rigid limits on levels of payments to phy-
sicians who provide services appear in contra-
diction to Congressional intent” that these pa-
tients receive care on the same basis as private
patients. A call was made for the Congress to
reassess its intent and priorities in relation to
Title XIX.

The AMA again asked for the identities of
physicians said to have abused Medicare and
Medicaid and condemned the practice of release
by government agencies of gross amount paid to
individuals and groups under the programs with-
out further explanation, giving a frequently false
impression of abuse.

Your Delegates introduced a resolution in re-
sponse to the mandate given us in Resolution
No. 3, subject: JAMA Laboratory Advertising, at
our 101st Annual Session. A number of similar
resolutions were introduced by other states. De-
spite diligent and persistent effort, the House con-
curred with the Judicial Council’s views that the
advertising pages of Journal AMA cannot be de-
nied a lawful activity, including independent lab-
oratories with industrial sponsorship.

The frequently discussed and sometimes mis-
understood position on medical care as a right
was clarified to the extent of a policy statement:

— That it is a basic right of every citizen to
have available to him adequate health care.

— That it is a basic right of every citizen to
have free choice of physician and institutions in
obtaining medical care.

— That the medical profession, using all means
at its disposal, should endeavor to make good
medical care available to each person.

A preliminary policy on health care of the
poor states that comprehensive services in this
connection are desirable, that it must be a long-
range, continuing program, that research on un-
met needs which is documented should be im-
plemented, that the poor should participate in
planning at community level, and that physicians
should work with organizations in and out of

medicine where concern for care of the poor has
been expressed.

The Scientific Assembly was reorganized with
the several specialty societies having been given
a stronger voice in the affairs of their respective
sections. Each of the 24 scientific sections is to be
governed by a section council whose members
are selected by the appropriate specialty society.
The new format becomes effective Jan. 1, 1972.

By-Laws relating to membership eligibility
were amended to permit qualified osteopaths to
become full, active members. While conceding
that the primary responsibility for family life edu-
cation is in the home, the House “supported in
principle the inauguration by State Boards of
Education or school districts, whichever is appli-
cable, of a voluntary family life and sex educa-
tion program at appropriate grade levels.” The
House supported the integrity of hospital medi-
cal staffs in self-government, having previously
endorsed the concept of voting membership on
hospital governing boards for physicians.

The financial picture for AMA is not bright
with mounting costs, broadened areas of activity,
and about $4 million due in federal income taxes
on advertising. We forsee a dues increase to $100
per year effective in 1971.

At the New York convention, the House of
Delegates took a unique action, electing a num-
ber of senior state medical association and na-
tional specialty society executives to membership
in AMA. Our Executive Secretary, Mr. Row-
land B. Kennedy, was among them.

Denver Clinical Convention. Major actions at
the Denver Clinical Convention included con-
clusive actions on health care of the poor, long-
range planning for AMA, discontinuation of the
AMA-ERF Institute for Biomedical Research, a
statement of policy on marijuana, private prac-
tice, governmental delivery programs, and costs
of medical care. The House of Delegates acted
on 99 items of business among which were 33 re-
ports and 66 resolutions.

In taking definitive actions on health care of
the poor, the House reaffirmed its policy on medi-
cal care as a basic right, calling for increased
funding of effective government programs, proj-
ects to eliminate unfavorable environmental con-
ditions, increased physician services in the urban
slums, expansion of health careers by recruitment
from disadvantaged areas, better prenatal and
postnatal care, family planning services, a crack-
down on quackery which exploits the poor, im-
proved mental health services programs, and
more participation in AMA activities by minority
group physicians.

(Turn to page 200)

APRIL 1970

189

The President Speaking

‘Continuum of Crisis’

JAMES L. ROYALS, M.D.

Jackson, Mississippi

Being President of the state medical association when the Legis-
lature is in session is an interesting and an enlightening experi-
ence. Last summer with the special session to consider Medicaid
and this year with the regular session in full swing, it seems almost
as if the Legislature has been meeting continually. And, hardly
does one crisis begin to pass before another more serious one ap-
pears.

Many issues of great importance to the practice of medicine in
Mississippi have been before these two sessions of the Legislature.
While we are fortunate to have many good and staunch friends
in the Legislature, it is realistic to recognize that organized medi-
cine is increasingly under attack.

Much of the hostile feelings which we have on occasions ex-
perienced can be explained by lack of proper communication
with the Legislature. In our busy days, we simply have not taken
the time or made the effort to communicate on a personal basis
with our legislators so that they may more properly understand
our points of view. We must organize ourselves so that our mem-
bers will be more adequately informed on issues under considera-
tion and bring our membership to an understanding of the abso-
lute importance of participating from a position of knowledge in
the great debate on delivery of health care that looms on the hori-
zon. We must increasingly and individually become involved with
our lawmakers, helping them draft legislation that will serve the
best, long-range interest of the public and preserve the free en-
terprise system that has made American medicine the greatest in
the world. ***

1 90

JOURNAL MSM A

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 4

April 1970

Professional Corporations:

They’re Here!

i

Ten months to the day after adoption of Reso-
lution No. 6 by the association’s House of Dele-
gates in 1969, professional corporations for Mis-
sissippi physicians are a legal reality. On March
16, the first citizen of the state guided his pen
across the engrossed copy of House Bill 48, af-
fixing the familiar signature, “John Bell Williams,”
as the president of the association stood at his
side. We not only have a professional corpora-
tion law, but we have an unusually good one.

The West Mississippi Medical Society, consist-
ing mostly of Vicksburg physicians, introduced
Resolution No. 6 at the 101st Annual Session,
seeking association approval and endorsement of
professional corporations and asking that a suit-
able bill be prepared and introduced in the Leg-
islature to make these legal entities possible. The
MSMA team took it from there, and our bill
was introduced by Hon. Fred Lotterhos of Jack-
son, a member of the House of Representatives
and respected practicing attorney. Much work
was done on the bill in the House Committee on
the Judiciary, and physicians owe a debt of grati-
tude to Hon. H. L. Merideth of Greenville, the
committee chairman, who conducted hearings, in-
vestigations, and sessions of the committee not
only to secure passage of the measure but to

strengthen it as well. The bill passed the Senate
without change.

Not every Mississippi physician will find it ad-
vantageous to incorporate, nor will it even be
economical to some. But for many, there are tax
benefits aplenty over anything else available. In
fact, physicians are almost equal — but not quite
— to their business and industrial counterparts
before the awesome majesty of the Internal Rev-
enue Service. And it’s about time, too.

II

The state medical association’s bill amends
Section 5390-42 of the Mississippi Code of 1942,
Annotated, to define “professional service” as a
personal service to the public which “requires as
a condition precedent to the rendering of such
service the obtaining of a license or other legal
authorization and which prior to the passage of
this act and by reason of law could not be per-
formed by a corporation.”

Any corporation formed under the act will
exist for the sole and specific purpose of render-
ing professional services. Its shareholders are re-
stricted to individuals “who themselves are duly
licensed or otherwise legally authorized within
the state to render the same professional service
as the corporation.”

cd

; 1

j

.7

\1

s

§

o

APRIL 1970

191

EDITORIALS / Continued

The enactment also amends Section 5390-43 to
define who may organize a professional corpora-
tion. In response to an amendment to Resolution
No. 6 on the floor of the House last year, the
law permits a single or solo practitioner to incor-
porate, as well as two or more. But most impor-
tant of all, professional corporations enjoy the
same privileges and benefits as are permitted
under the Mississippi Business Corporation Act,
except for the limitation of corporate activities
or the practice of the profession. This was an-
other substantial service performed for the pro-
fession by Chairman Merideth and his colleagues
of the House Committee on the Judiciary.

III

Since enactment of the federal income tax in
the era of World War I, self-employed profession-
al individuals have been behind the tax collec-
tor’s eight ball. In the decade of the 1950’s, medi-
cine opposed compulsory Social Security cover-
age for physicians. This also meant opposing pro-
fessional corporations, because the Social Secur-
ity Act required this taxation upon every cor-
porate employee. Rather, American medicine
went for Keogh and voluntary tax-deferred re-
tirement programs for the self-employed.

We got Keogh, and there is something in it for
just about every self-employed professional indi-
vidual, generally, much more for some than for
others. It is a good, sound law which is not sub-
ject to the whims of judicial fiat in tax litigation.
But for most, it is half a loaf: A self-employed
individual can’t even deduct his personal hospi-
tal insurance premium under it.

The professional corporation opened up new
vistas, and the issue of mandatory coverage for
physicians became academic and rhetorical in
1965 with the enactment of Public Law 89-97,
Medicare and Medicaid, which also blanketed
the M.D. into Social Security. The long road
through the courts for the professional corpora-
tion, blocked at every turn by the Treasury De-
partment and Internal Revenue Service, is a fa-
miliar story to physicians. In 1969, the Treasury
Department, with a zero record in the courts,
announced that no further litigation would be
pursued against professional corporations. The
way was apparently clear for the Mississippi ac-
tion as mandated in Resolution No. 6.

IV

House Bill 48 is far more than a vehicle for
tax-sheltered retirement plans, but this is the

principal benefit. The corporation may cover its $
employees (and owner-employees) with one or to
more deferred compensation plans qualified un- i
der Section 401(a) of the Internal Revenue Code «
of 1954, deducting from federal taxes all con-
tributions to such plans.

Moreover, beneficiaries are deemed to have
received no taxable income until payment of
benefits. A plan may provide for progressive
vestment, and amount so owned may be en-
joyed by the beneficiary-owner at any time with
payment only of income tax due. Under Keogh,
this is not possible.

The corporation may purchase group life, ac- j
cident, and health insurance for its employees, |
deducting from taxes all premiums paid. Most |
such plans are noncontributory, meaning that the |
corporation pays the full amount. For federal
tax purposes, professional corporations may pay
death benefits of as much as $5,000 which are
not only fully deductible for tax purposes but j
which are also not taxable to recipients.

Corporations may establish a plan for sick
leave payment for employees, usually at full
salary, and deduct all such costs from taxes.
Employees receiving such benefits may deduct
from personal income taxes up to $100 per week
of benefit payments. Corporate employees are
fully covered by Workmen’s Compensation, and
the costs of the coverage are tax-deductible to
the corporation with tax-free benefits to employ-
ees. A corporate employee may even exclude
from gross income meals, lodging, and travel ex-
pense furnished by the corporation under cer-
tain circumstances.

V

But a note of caution: Proceed with the same
care which is required in any serious and sub-
stantial business transaction. In the next few
months, Mississippi physicians will be deluged
with mail and hordes of salesmen, investment
counselors, insurance agents, mutual fund repre-
sentatives, pitchmen of every degree and shade,
and perhaps an occasional bank vice president.
They are after just one thing: Your corporate
funds in their own particular type of investment.

Most of these salesmen will have lawful and
sound programs to offer. Their main selling point
will be relief of detail and administration for the
busy physician. Some few will have plainly poor
programs to sell, and dealing with them would
be a tragic mistake.

For the physician or medical group feeling
that the professional corporation offers the most
and best advantages, call in the certified public

192

JOURNAL MSM A

accountant who regularly examines accounts and
' counsels on taxation. Consultation with an at-
torney is also time well spent. Look critically into
- your individual tax situation and practice orga-
nization. Some are going to find that the Keogh
route is as good as the corporation without the
e attendant costs and detail. Others — many, we
trust — will find substantial advantage in the cor-
* porate vehicle.

But whatever the case, begin with competent
and preferrably independent professional evalua-
tion and screening before making a decision. Be
certain that corporations conform to the IRS
regulations of 1965 which were aimed at and
against professional corporations: Your organiza-
tion must have more corporate characteristics
than those of a partnership or trust to qualify.
IRS still denies tax benefits to some professional
corporations on this basis.

Be certain also to look over all plans avail-
able, because one may be best for a given tax
and practice situation. Deal with reputable, es-
tablished institutions and organizations in the cor-
porate finance market.

The association has carried this assignment
from the membership to completion, another
team project which has paid off. The association
will now devote its efforts toward the interests of
j those who elect to use this vehicle. — R.B.K.

Complete Care of
the Whole Man

“I don't want any preacher around upsetting
my patients.”

This remark is attributed to one Dr. Orville S.
Walters writing in the Illinois Medical Journal
quite a few years ago. Now his state medical so-
ciety, along with all of its sister associations and
societies, has a useful, viable program in medi-
cine and religion.

The Mississippi State Medical Association pio-
neered this program, presenting what was prob-
ably the first state symposium on medicine and
religion in 1963. The AMA program has pros-
pered under the skillful leadership of the Rev.
Dr. Paul B. McCleave and the 20-member Com-
mittee on Medicine and Religion.

Mississippi is proud that one of the 10 repre-
sentatives of the clergy and rabbinate is the Most
Rev. Joseph B. Brunini, bishop of the Diocese of
Natchez-Jackson which embraces our state. Bishop
Brunini has given valuable leadership and sup-

port to this AMA program, having been first ap-
pointed to serve as one of two Catholic representa-
tives with the popular and distinguished Bishop
Fulton J. Sheen.

The seven-member Committee on Medicine
and Religion of the association is a constitutional
body of the Board of Trustees. Its program is
expanding as it reaches into our communities and
major medical institutions. Component societies
of the association have associated themselves in
the work of treating the whole man and promot-
ing closer understanding between physicians and
clergymen and rabbis. Only recently, a major
presentation was sponsored by the Central Med-
ical Society at Jackson with state committee sup-
port and participation.

This is a program which may be implemented
in a community with only one physician and one
minister. And how much more is it needed in
the larger communities with many physicians
and churchmen. AMA will supply materials, and
the state association committee stands ready to
offer suggestions and guidance.

What was once a conflict between the physi-
cian and the man of the cloth, so well illustrated
by Dr. Walters’ observation, is fast becoming a
useful partnership serving the needs and well-
being of the patient. It has been wisely observed
that a man may be without a denomination but
he is not without a faith. Let us give more than
the miracles of science in the care of the whole
man and lend our support and conscientious ef-
fort to this vital program. — R.B.K.

Malihus and
Meat Analogs

Malthus was right, although it has taken us
two centuries to find that out. At the rate we are
going, the world's population will outstrip the
food supply. Of course, human hunger and mal-
nutrition are favorite vehicles for making politi-
cal hay. It is fashionable to decry half the world’s
going to bed hungry or ill-fed.

This may soon come to mean half of suburbia,
too, if you’ve been to the supermarket lately and
looked at the food prices. There’s no question
about it: If the Big Board on Wall Street had
the upswing record of cheese, meat, canned corn,
and peanut butter, we'd have a society of wealthy
shareholders.

But everywhere on the horizon are evidences
of American ingenuity, and there’s hope in the

APRIL 1970

193

EDITORIALS / Continued

supermarket yet. The most recent development
is meatless meat, and it has medical, social, and
economic implications.

Just about everybody knows how good General
Mills’ BacOs® can be on the salad or scrambled
eggs. This synthetic product, tasting devilishly
close to $1.10 per pound bacon, is among the
first of the successful meat analogs, so named as
being “analogous” to meat.

But joy for Mississippi, meat analogs are made
mostly from soybeans. They are nutritious, tasty,
and much less expensive than meat. In northern
test markets, there are ersatz meat loaf, luncheon
slices, meatless meat pies, hamburger(less) pat-
ties, and even “Stripples,” a Worthington bacon-
like strip which for 79 cents yields up about the
same number of servings as two pounds of ba-
con.

The process involves “spinning” soybean fiber
and then shaping and flavoring it like meat. There
are fat and flavor fillers, colorings, and slicing.
Many claim that it is just another impulse item,
but in industrial cafeteria tests, workers ate ana-
logs with relish, and most didn’t complain after
being told that the meat was meatless. Now,
Swift and Co. is about to introduce a revolution-
ary extrusion process which may open the market
up wide.

Does this portend ill for the livestock indus-
try? Absolutely not, because meat-hungry Amer-
icans will continue to clamor for U. S. prime
ribeye steaks. But it is no secret that the price is
going out of sight, because protein for cattle is
costly in feeds and grazing. Above all, there will
be progressively more people to eat a diminish-
ing supply of food.

Analogs will get progressively better, as tech-
niques improve. One meat processor has a steak
which is hardly distinguishable from the real Mc-
Coy in appearance and feel. It is a little mushy
in comparison with the best grade of beef, but it
is also about a third of the price.

So far, nobody has come up with a causal con-
nection between the components of analogs and
cancer, mental retardation, or crossed eyes. The
nutritive values appear to be well-established,
and the economic possibilities suggest that meat,
in analog form, may soon be back on low income
tables. All of this is to say that we may continue
to feed ourselves in spite of runaway procreativ-
ity. — R.B.K.

April 1-3, 1970

SEVENTEENTH ANNUAL f

CARDIOVASCULAR SEMINAR L

University Medical Center, Jackson
April 1,2, 3, 1970, beginning at 8:30 a.m.

Sponsored by the Mississippi Heart Association
and The University of Mississippi School of
Medicine

Participants:

Jack W. Fleming, M.D., cardiologist, and direc-
tor, Project Coronary Care, Medical Center !
Clinic, Pensacola, Florida

Noble O. Fowler, M.D., professor of medicine, !
The University of Cincinnati College of Med-
icine and director, Cardiac Research Labora-
tory, Cincinnati General Hospital, Cincinnati,
Ohio

John A. Chadbourn, M.D., assistant professor of
clinical medicine and co-director, Mobile Coro-
nary Care Unit, New York University-Bellevue
Medical Center, New York, N. Y.

Lawrence E. Lamb, M.D., professor of medicine,
Baylor University College of Medicine, Hous-
ton, Texas

“ The sponge count is correct, Doctor, but my
lucky rabbit's foot is missing!”

194

JOURNAL MSM A

Derward Lepley, Jr., M.D., professor of thoracic-
cardiovascular surgery and chairman of the
department, Marquette University School of
Medicine, Milwaukee, Wisconsin

Madison S. Spach, M.D., chief of the division of
pediatric cardiology, department of pediatrics,
Duke University School of Medicine, Durham,
North Carolina

Wednesday Morning

Experiences in Mass Screening Electro-
cardiography
Dr. Lamb

Mobile Coronary Care Ambulancing
Dr. Chadbourn

Intracardiac Shunting Mechanisms and
their Influence on Ventricular Per-
formance in Congenital Heart Disease
Dr. Spach

Pediatric Grand Rounds

Wednesday Afternoon

Intermediate Coronary Care Units
Dr. Chadbourn

Mobilizing Community Resources for Coro-
nary Care
Dr. Fleming

Valvular Replacement
Dr. Lepley

Discussion

Thursday Morning

The Current Role of Isopotential Surface
Mapping in Clinical Electrocardiog-
raphy
Dr. Spach

Myocardial Disease
Dr. Fowler

Coronary Surgery: Direct Reconstruction
Dr. Lepley

Surgery Grand Rounds

Thursday Afternoon

Pericardial Disease
Dr. Fowler

Exercise and the Cardiovascular System
Dr. Lamb

Current Major Diagnostic and Therapeutic
Problems in Children With Heart Dis-
ease

Dr. Spach

Discussion
Friday Morning

The Failing Heart in Acquired Heart Dis-
ease

Dr. Lepley

Clinical Palpation and Portable Record-
ing in Evaluating Common Cardiac
Problems
Dr. Fleming

Modern Treatment of Paroxysmal Arhyth-
MIAS

Dr. Fowler

Medicine Grand Rounds

Cardiovascular Studies in Astronauts, Air-
crews and Athletes
Dr. Lamb

CIRCUIT COURSES
Eastern Circuit

Meridian — April 7 — Session 2; May 5 — Ses-
sion 3, East Mississippi State Hospital,
6:30 p.m.; Briarwood Country Club,
6:30 p.m.

Columbus — April 28 — Session 3, Downtown-
er Motor Inn, 6:30 p.m.

Session 2 — Respiratory Failure: Current

Methods of Management, Dr. Boyd
Shaw

Surgical Management of Emphysema, Dr.
William Fain

Session 3 — Complications Associated With
Saddle Block Anesthesia in Obstetrics,
Dr. Donald Sherline

The Management of Edema Related to
the Kidney, Dr. Ben B. Johnson

Southwest Circuit

McComb — April 7 — Session 3, Southwest Mis-
sissippi General Hospital, 7 :00 p.m.
Natchez— April 21 — Session 3, Jefferson Da-
vis Memorial Hospital, 7:00 p.m.

Session 3 — Headache

Neurological Approach, Dr. Armin Haer-
er

Neurosurgical Approach, Dr. Robert R.
Smith

FUTURE CALENDAR

March 16-20, 1970

Cardiology Intensive Course
Stroke Intensive Course

APRIL 1970

1 95

POSTGRADUATE / Continued

April 1-3

Cardiovascular Seminar
A pril 7

Circuit Course, McComb
Circuit Course, Meridian

April 16

Mississippi Thoracic Society
April 21

Circuit Course, Natchez

April 28

Circuit Course, Columbus
May 5

Circuit Course, Meridian
May 11-14

Mississippi State Medical Association

William E. Bobo of Clarksdale has conducted
cardiopulmonary resuscitation training sessions
for physicians from the Greenwood Leflore Hos-
pital, King’s Daughters Hospital of Greenville,
General Hospital of Greenville, and the East
Bolivar Hospital of Cleveland, at the General
Hospital in Greenville.

Tommy Brooks of Jackson was among gem cut-
ters and collectors who exhibited their gems at
the 11th annual Mississippi Gem and Mineral
Society show in February. Dr. Brooks is a past
president of the society.

Robert S. Caldwell of Tupelo and John M.
McRae of Laurel have been appointed to the
Boards of Directors for the University of Mis-
sissippi Alumni Association and the Medical
Alumni Chapter.

Charles N. Cannon has begun the general
practice of medicine and surgery at Philadelphia.
Dr. Cannon’s offices are located at 587 E. Main.

James Doster of Columbus has been named a
new director of the 1970-71 Columbus-Lowndes
Community Fund.

William M. Flowers of Jackson spoke on
radioisotopes and scanning to the medical staff of

Southwest General Hospital at McComb. The
hospital is considering installing radioisotope nu-
clear equipment in the x-ray department.

William A. Gary has associated with R. B.
Robinson of Saltillo in the practice of general
medicine at the Saltillo Clinic.

Guy T. Gillespie, Jr. of Jackson announces the
removal of his office for the practice of hema-
tology and chemotherapy to 710 Gillespie Street
in Jackson.

William E. Godfrey, III; Thomas L. Purvis, f
Jr.; Donald E. Killelea; and Louis C. Leh-
mann, of Natchez have announced the removal
of their offices to 136 Jefferson Davis Boulevard.

Carl R. Hale of Hattiesburg has been appoint-
ed stockholder representative for Forrest County
of Kimbrough Investment Co., Jackson, owners '
and operators of the Sheraton-Biloxi.

Gov. John Bell Williams has appointed the fol-
lowing physicians to a 40-member committee to
study the problems of children and young people
in preparation for the 1970 White House con-
ference: William E. Lotterhos, Robert E.
Carter, Noel C. Womack, Jr., Claude G.
Sutherland, Mary Alice Lee, Hugh Cot-

”But, how could I be? — He never once missed
taking his pill.”

196

JOURNAL MSM A

trell, and Frank Wiygul, all of Jackson. Drs.
Lotterhos and Carter were appointed co-chairmen
of the committee.

L. L. McDougal of Tupelo was awarded the
Outstanding Citizen Award posthumously during
the city’s annual Junior Auxiliary Charity Ball.

C. B. Mitchell of Starkville has presented 27
shares of IBM stock to the Mississippi State Uni-
versity Development Foundation to be restricted
to the C. B. Mitchell Pre-Med Fund. The gift
qualifies Dr. Mitchell, retired university physi-
cian, as a member of the Patrons of Excellence
program.

A. C. Pickle of Kosciusko instructed physicians
at Tyler-Holmes Hospital of Winona in the tech-
niques of cardiopulmonary resuscitation at a Mis-
sissippi Heart Association-sponsored training
course.

Ernest P. Reeves of Collins has been elected
director of First Guaranty Savings and Loan As-
sociation. Formerly advisory director. Dr. Reeves
was elected to full directorship at the annual
board meeting.

T. E. Ross, III of Hattiesburg recently presented
a workshop on cardiac resuscitation at the South
Mississippi Medical Auxiliary meeting in Hatties-
burg.

I E. J. Schmidt of Bude has been named citizen
of the year at a banquet at Franklin County’s
Middlefork Country Club.

C. D. Taylor, Jr. of Pass Christian served as
president of the St. Paul’s Mercy Carnival Asso-
ciation which sponsored the annual Mardi Gras
parade.

Cooke, James Kenneth, Jackson. M.D., Uni-
versity of Tennessee College of Medicine, 1948;
postgraduate training in psychiatry at Tulane
University and child psychiatry at the University
of Indiana; died Feb. 1 1, 1970, age 57.

Pitchford, Ruth Dean, Canton. M.D., Univer-
sity of Virginia; died Feb. 24, 1970, age 71.

The following physicians have been elected to
membership by their respective component Med-
ical Societies in the Mississippi State Medical As-
sociation and the American Medical Association.

Miller. Richard Charles, Jackson. Born Hart-
ford, Conn., Nov. 6, 1929; M.D., Harvard Med-
ical School, Boston, Mass., 1955; interned Uni-
versity Hospitals of Cleveland, Ohio, one year;
surgery residency, same, July 1, 1956-June 30,
1957, and July 1, 1959-June 30, 1962; fellow-
ship in pediatric surgery. Royal Children’s Hos-
pital, Melbourne, Australia, 1963-64; elected
Jan. 6, 1970 by Central Medical Society.

Rester, Robert Raymond, Jackson. Born Jack-
son, Miss., Oct. 8, 1932; M.D., University of
Mississippi School of Medicine, Jackson, 1968; in-
terned same, one year; elected Nov. 4, 1969 by
Central Medical Society.

Speck, James W., Ecru. Born Pontotoc, Miss.,
April 26, 1941; M.D., University of Mississippi
School of Medicine, 1967; interned Mobile Gen-
eral Hospital, Ala., one year; elected Dec. 3,
1968 by Northeast Mississippi Medical Society.

Sprabery, Archie Patrick, Fulton. Born Tupe-
lo, Miss., Dec. 18, 1942; M.D., University of
Mississippi School of Medicine, Jackson, 1967;
interned Mississippi Baptist Hospital, Jackson, one
year; elected Sept. 19, 1969 by Northeast Missis-
sippi Medical Society.

Walden, Thomas Beall, Brookhaven. Born
Georgetown, Miss., April 15, 1937; M.D., Uni-
versity of Mississippi School of Medicine, Jackson,
1962; interned, same, one year; pathology resi-
dency, same, July 1, 1963-June 30, 1967; elect-
ed by South Central Mississippi Medical Society.

White, Ellison Fred, Houston. Born Brook-
haven, Miss., April 7, 1916; M.D., University of
Tennessee College of Medicine, Memphis, 1942;
interned Baptist Memorial Hospital, Memphis,
Tenn., one year; fellow in medicine, Mayo Foun-
dation for Medical Education and Research, Mayo
Clinic, 1943-1947; University of Minnesota
Graduate School of Medicine, M.Sc. (Medicine)
1947; elected Dec. 3, 1968 by Northeast Mis-
sissippi Medical Society.

APRIL 1970

197

ORGANIZATION / Continued

Pharmacy School
Organizes Museum

Directions on the cough remedy bottle were
printed in nine languages — from English to Nor-
wegian, French to Yiddish — but something else
was unique about the medicine ... it only cost
34 cents.

Consequently, although a mere 40 years old,
the “international” cough medicine has become
a part of the University of Mississippi School of
Pharmacy’s newly organized Pharmacy Museum.

Purpose of the museum, according to Pharma-
cy School Dean Charles W. Hartman, is to record
history and illustrate progress in the profession in
both theory and practice.

Examining antiques once used in an old Mississippi
pharmacy, and now a part of the University of Mis-
sissippi School of Pharmacy’s Museum, are (from
left) Jill Patrick of Tallapoosa, Ga. and James
Scruggs of Atlanta, Ga. The museum is located in
the School of Pharmacy’s new building at Ole Miss.

“The museum was unveiled last June when
we moved into our new building,” he explained,
“although we have been collecting items since
1961, when we began asking pharmacists in Mis-
sissippi for artifacts of historical interest.”

Dean Hartman said there are presently between
1,000 and 2,000 items in the collection but added :
that all are not yet on display.

To be featured in the museum when all dis-
play areas have been filled will be old drugs,
prescription journals, pill tiles, antique weights
and balances, grinding mills, apothecary jars, and
even an old-fashioned marble-topped fountain
table and chairs.

Representative among the dark bottles with
faded labels is Professor Guilmitte’s French Kid-
ney Pads “guaranteed to cure any person . . .
who has lame back, gravel, diabetes, Bright’s
disease of the kidneys, catarrh of the bladder,
general weakness, dropsy.”

Or there is the remedy with the simple but ;
highly appropriate name of “Pain Killer,” which
could be swallowed or rubbed on, depending on i
one’s ailment. Internally, it solved problems of 1
cramps, colic or colds; externally, it was dandy I
for insect stings, muscular strain, or minor in- 1
juries.

A special feature of the museum is a section I
devoted to the first dean of the Ole Miss School
of Pharmacy, Henry Minor Fraser, for whom
the building will be named in later formal cere-
monies.

The section contains Dean Fraser’s citations,
scrapbook, watch, and a letter to Gov. Lee Rus-
sell after graduation from a recognized school of
pharmacy became a prerequisite for becoming a -
licensed pharmacist. Also in the collection is the !
pen with which the governor signed the law.

Although undedicated, the museum is already
open to the public.

EEG Course Set
for September

A continuation course on “Current Practice of
Clinical Electroencephalography” will be held
Sept. 14-16, 1970, in Washington, D. C. The
course is designed to review the principal appli-
cations of the EEG to clinical medical practice,
and is sponsored by the American Electroenceph-
alographic Society.

Inquiries about further details of the course or
registration procedure should be addressed to Dr.
Donald W. Klass, EEG Course Director, Mayo
Clinic, Rochester, Minn. 55901.

I 98

JOURNAL MSMA

Book Reviews

Manual on Artificial Organs. Vol. I, The Arti-
icial Kidney. By Yukihiko Nose, M.D., Ph.D.
143 pages with illustrations. St. Louis: The C. V.
Mosby Company, 1969. $27.75.

Few books have been written for the physician
and his patient. This is one of those books. This
stems from the fact that hemodialysis is a relative-
ly new venture for both of these parties. For this
reason, portions of the book seem fundamental at
first glance, but these concepts are essential to
the basic comprehension of the principles of
dialysis. The interrelationship and interaction of
man and a machine responsible for the mainte-
nance of his life require this type of information.
This book helps to bring this concept into sharp
focus both for the physician and his patient.

The book is well written using many excellent
detailed illustrations. It covers the broad field of
dialysis ranging from the history of dialysis to
future planning and optimal design of commu-
nity kidney care centers. It also contains detailed
description on the technique of peritoneal dialy-
sis. This is probably the best analysis of this topic
to date for medical and paramedical personnel.
The author gives an accurate appraisal of existing
dialysis equipment. In addition, he discusses the
future of dialysis equipment including the pos-
sibility, and feasibility of wearable and implant-
able artificial kidneys. The largest portion of the
book is directed toward the major problems in
dialysis today. Considerable time is spent on the
care and maintenance of permanent access to the
human blood stream. The newer internal A-V
fistula is described and evaluated very well. The
medical complications of long term chronic hemo-
dialysis are also presented along with the cur-
rent state of the art toward prevention of these
complications.

The book has an excellent index and con-
tains many pertinent references that will permit
the reader to delve as deeply as desired into dial-
ysis technology, clinical results and research re-
lated to this field.

This book definitely has a place in the office of
any physician involved in any form of dialysis.
It will make a good teaching text for patients,
physicians, nurses and technicians in the home
and satellite hemodialysis programs of Mississip-
pi.

John D. Bower, M.D.

Current Practices in Orthopaedic Surgery.
Edited by John P. Adams, B.S., M.D., F.A.C.S.
279 pages with 322 illustrations. St. Louis: The
C. V. Mosby Company, 1969. $22.50.

This fourth volume of Current Practice in
Orthopaedic Surgery is edited by John P. Adams,
M.D. This and previous volumes have been an
annual review of current practices in orthopaedic
surgery with each article being an interpretation
of the literature, explained and when necessary
enlarged upon, according to the concepts of well
qualified authorities.

The nine contributors of this volume have not
only interpreted the literature on their respective
subjects but also advanced their own thoughts on
the matter.

The topics covered in this edition help to clari-
fy “current practices” in several important areas
of orthopaedic surgery. It consists of 279 pages
and 322 illustrations. There are three primary
sections. The first section is an interesting and en-
lightening history of American orthopaedic sur-
gery by Dr. Alfred R. Shands. Section two covers
general orthopaedic surgery and includes con-
genital talipes equinovarus, femoral intertrochan-
teric osteotomy for arthritis of the hip, fractures
and dislocations of the cervical spine (diagnosis
and treatment), and flexion deformities of the
fingers.

Section three is a miscellaneous section and in-
cludes current aspects of shock management, re-
gional anesthesia in the upper limbs, and manual
muscle testing of the trunk and lower extremities.

While the volume does not serve as a complete
text, it certainly has a good deal to offer as a
reference to those topics mentioned above. I feel
that it is a worthwhile addition to my library.

William B. Thompson, M.D.

APRIL 1970

199

HOUSE OF DELEGATES / Continued

The Report of the Committee on Planning and
Development for AM A (Himler Report) was re-
ceived formally by the House of Delegates. In-
stead of generating the anticipated controversy,
the report was discussed and handled with lit-
tle fanfare. The House established an ad hoc
committee to receive the report, to recommend
methodology for a permanent committee, and to
send the report to state associations requesting
resolutions for consideration at the 1970 annual
convention.

After years of discussion and debate, the
House of Delegates adopted as policy that “can-
nabis (marijuana) is a dangerous drug and as
such is a public health concern. It is a psycho-
active substance which can have a marked del-
eterious effect on individual performance and
social productivity. A significant number of ex-
posed persons become chronic users with con-
comitant medical and interpersonal problems.”

The House stated that the sale of marijuana
should not be legalized, saying that if potency
were legally controlled, predictably there would
be an illicit market for the more powerful forms.

The AMA-ERF Institute for Biomedical Re-
search, called a noble experiment, was discon-
tinued because of high costs. The House could
find no way to construct a permanent building
for the Institute, and there were no outside funds
available to assist AMA in supporting the multi-
million dollar activity.

The House created a Committee on Private
Practice, assigning it to the Council on Medical
Service. A proposal to establish a new Council on
Private Practice was not favorably considered.
Support for the Regional Medical Programs un-
der PL 89-239 was reaffirmed, but the delegates
opposed on-site auditing of physicians’ accounts
in their offices by government representatives.
Federal licensure was opposed, but state associa-
tions were urged to work with legislatures to
strengthen licensure laws. Physicians were asked
again to be mindful of care costs, as concern was
expressed over the ever-increasing costs of hos-
pital care. The Medicredit concept for voluntary
national health insurance was endorsed.

State medical associations were encouraged to
make active membership available to residents
and interns (a benefit available in Mississippi),
and dialogue with medical students was recom-
mended.

Expression of Delegates. Your AMA Delegates
express their appreciation to our own House of
Delegates, to the Board of Trustees, and to the

general officers for support and the mainte- P
nance of continuing communication. We sit withy
the Board at all meetings and are thereby en-
abled to be fully informed on all policy develop-
ments and positions. We pledge our best effort
in representing your wishes, desires, and policies
in the AMA House of Delegates.

j |

REPORT OF THE COUNCIL ON f

CONSTITUTION AND BY-LAWS

101st Annual Session. At the 1969 annual ses-
sion, the House of Delegates approved two
amendments to the By-Laws of the association,
both with reference to committees.

Section 2, Chapter IX, was amended to ac-
cord constitutional status to the Committee on
Blood and Blood Banking as a permanent com-
mittee of the Council on Medical Service. This
action did not, however, confer a vote in the
House of Delegates on the committee members,
since only elected officers, Trustees, and council
members have the vote.

Section 2, Chapter VI, was repealed as regards
a new nominating procedure instituted in 1968.
The traditional method of making nominations
was restored and will be followed during the
present annual session.

Two proposed amendments to the By-Laws at
the 1969 annual session failed. One was to make
the Speaker and Vice Speaker of the House of
Delegates ex officio members of the Board of
Trustees without vote and the other would have
empowered the Speaker and Vice Speaker to ap-
point reference committees.

102nd Annual Session. There are no pending
amendments to the Constitution or By-Laws lying
on the table. The council will stand in readiness
to consider any amendments which are proposed
at the present annual session.

REPORT OF THE COUNCIL ON
SCIENTIFIC ASSEMBLY

Organization and Duties. The Council on Sci-
entific Assembly is a constitutional body of the
House of Delegates, charged with the responsi-
bility of planning the annual session of the as-
sociation to include all scientific activities, the
programming, and the scheduling of the annual
session events. The council membership consists
of the chairmen and secretaries of the seven sci-
entific sections and the secretary-treasurer, a to-
tal of 15 members.

102nd Annual Session. Your council began
plans for the 102nd Annual Session in August
1969. The general format, previously ap-
proved by the House of Delegates, has been con-

200

JOURNAL MSM A

Limed with general sessions centering around
iroad areas of specialty interests. To the maxi-
nurn possible extent, conflicts in programming
lave been eliminated. The council, in many in-
tances, has requested and placed essayists be-
ore sections from the various specialty societies
lot represented in the Scientific Assembly. The
nembership is thereby given the benefit of the
presence of these speakers which might not oth-
erwise be available. The specialty societies con-
inue to work closely in these and other con-
lections to improve the quality and to enhance
:he attractiveness of our programs.

At the present annual session, about 12 spe-
;ialty groups, four medical alumni groups, and
various nonscientific but medically related bodies
will meet concurrently during May 11-14. We
believe that this arrangement offers variety and
combinations of benefits for the membership in
attendance.

We have scheduled film programs again im-
mediately before each scientific section. We are
gratified with the promising quality and interest
of our scientific exhibits, and we urge each mem-
ber and guest in attendance to avail themselves
of the benefits of the Technical Exhibit which
largely supports our annual session’s scientific
work.

Expression of the Council. Your Council on
Scientific Assembly is deeply grateful for the
support, cooperation, and assistance we have re-
ceived in planning the 102nd Annual Session.
We are especially aware of the problems con-
fronting our headquarters hotel complex result-
ing from the devastating experience of Hurricane
Camille. The Buena Vista organization has done
splendidly in restoring services and facilities to
fulfill our contract, and we will look forward to
future annual sessions scheduled for our Gulf
Coast.

REPORT OF THE JUDICIAL COUNCIL

Constitutional Responsibilities. Your Judicial
Council is one of eight elected councils of the as-
sociation and one of the three which reports di-
rectly to the House of Delegates. Under author-
ities contained in Section 4, Chapter IX, of the
By-Laws, the council is charged with the exer-
cise of the judicial powers of the association and
the interpretation and application of the Prin-
ciples of Medical Ethics of the American Medi-
cal Association. The rulings of the council are
subject to the will of the House of Delegates, and
its judicial decisions may be appealed to the Ju-
dicial Council of the American Medical Associa-
tion.

In the exercise of these powers and discharge
of its responsibilities, the council endeavors to
work with general officers, the Board of Trustees,
and component medical societies. At all times,
the council endeavors to be responsive to the
needs and requests of members of the associa-
tion.

Medical Ethics. At the 101st Annual Session
in 1969, your council reported seven opinions to
the House of Delegates relating to telephone di-
rectory listings, compulsory assessments upon
hospital staff members, transplantation of human
tissue, drugs and devices, treatment of obesity
(condemnation of the so-called “rainbow pill”
regimen), laboratory services, and use of bank
credit cards for payment of physicians’ fees.
Your council reaffirms these opinions.

Two physicians who are members of the asso-
ciation asked the council during the 1969-70 as-
sociation year to examine into a circumstance in
which it was charged that a third physician, also
a member who practiced in the same medical
community, occupied offices in a community
(Hill-Burton) hospital. The council, acting
through the chairman, requested the component
medical society to investigate the charge to de-
termine if sufficient basis existed for formal ac-
tion.

A committee of the component society, in-
cluding the district Trustee, conducted the inves-
tigation and found that the office in question was
merely in close proximity to the hospital with a
walkway. The society expressed the opinion that
no violation of law, regulations, or medical eth-
ics had occurred, and the council has considered
the matter closed. The Board of Trustees also
received a report in this connection through the
Trustee, also at the request of the council.

The council, acting on prior policies of the as-
sociation, issues the following opinion:

Physicians should not maintain offices for the
conduct of their regular private practice for care
of outpatients in community, county, nonprofit, or
church-affiliated hospitals. Exceptions are made
in the case of those physicians whose practice of
medicine is usually conducted in the hospital en-
vironment such as pathologists and radiologists.
The proscription does not apply to the private
proprietary hospital or to physician-owners when
the medical staff approves the practice.

Discipline. The council has conducted no for-
mal proceedings as to disciplinary matters either
by original jurisdiction or on appeal during the
association year. We stand ready, however, to
respond to any need where and when necessary.

AMA Judicial Council. All opinions and de-

APRIL 1970

201

HOUSE OF DELEGATES / Continued

cisions of the AM A Judicial Council are regular-
ly reviewed, and each member of your council
maintains a compendium of these opinions and
decisions which are secured and distributed
through our association’s executive office.

REPORT OF THE COUNCIL ON
MEDICAL SERVICE

Organization and Duties. The Council on
Medical Service is a constitutional body of the
House of Delegates. It is charged with the re-
sponsibility of ascertaining and studying all as-
pects of medical care in Mississippi. Under the
council’s jurisdiction are assigned activities of the
association in medical service, emergency ser-
vice programs, medical care for the indigent, and
the work of allied medical agencies. The council
is assisted in its work by four constitutional and
three ad hoc committees. Programs, studies, and
activities of the several committees embraced a
wide range of subject areas and policy develop-
ment and implementation during the 1969-70 as-
sociation year.

Committee on Maternal and Child Care. The
committee continues to pursue its study of ma-
ternal deaths in Mississippi, and during the year,
it marked a full decade of these studies. The data
have been processed on the association System/
360 computer, and selected papers from the
studies have been published in the Journal. At
the 101st Annual Session, the committee present-
ed a scientific exhibit on its work.

Of particular interest is a recent substudy of
anesthesia-related deaths in the series, and this is
being presented in the Scientific Assembly at your
102nd Annual Session. The committee works
closely with the Department of Obstetrics and
Gynecology of the University Medical Center.

The committee continues to make available
sets of “Maternal Health Desk Cards” which are
distributed to hospitals through chiefs-of-staff and
chiefs of ob-gyn services. The committee con-
ducts regular quarterly meetings to pursue its
duties and review case studies. The chairman is
Dr. William B. Wiener of Jackson, and the com-
mittee has seven members and three consultants
in medicine, pathology, and anesthesiology.

Committee on Mental Health. Continuing its
work in broad areas of mental health, the com-
mittee has been acutely aware of problems in
drug addiction. During the year, it has conduct-
ed educational activities in this connection and
made materials available to physicians who have
addressed school, youth, and other nonmedical
audiences on the subject.

The committee reports that seven of the nm
multi-county regions in Mississippi now havi
mental health centers or are preparing to becomi
operational in the near future. Centers are al
ready open at Tupelo, the first in the state, am
at Oxford. Units for Jackson and Greenville art
under construction, and plans are in advances
stages for centers at Meridian, Clarksdale, anc
Gulfport. The program has grants totaling $3.7
million.

The chairman is Dr. John J. Head of Whit
field, and the committee has seven members.

Committee on Occupational Health. The com-
mittee, charged with study of all aspects of oc-
cupational health, continues to pursue an inter-:
est of a suitable and adequate legal base foi
Workmen’s Compensation in Mississippi. Thq
1968 amendments covered occupational disease!
Additional measures were pending before the
1970 Regular Session at the time of preparation i
of this report.

The committee continues to have interest in
publishing papers in this area of interest in the!
Journal.

The chairman is Dr. George D. Purvis of Jack-,:
son, and the committee has seven members.

Committee on Blood and Blood Banking. Thi&
committee was accorded constitutional status by!
the House of Delegates at the 101st Annual Ses-:
sion in 1969. It has been active in conducting
Congressional liaison in connection with National
Blood Donors Week and in the issue of a com-
memorative postage stamp on blood donors in a
cooperative effort to focus attention on this acute
need.

The committee has further pursued studies on
computer-based blood bank inventory informa-
tion systems and intends to institute, at the ear-
liest practicable time, a pilot project making use
of the association’s computer. Modest financing
will be required, and the possibilities of secur-
ing this from participating medical institutions
will be explored prior to requesting support funds.
The committee has also considered the possibil-
ity of a grant application for a demonstration
project. When and if such a decision is reached,
the matter will be subject to the usual approval
procedures traditionally followed.

The chairman is Dr. Kenneth M. Heard of
Jackson, and the committee has seven members.

Committee on Nursing (ad hoc). The commit-
tee has been intensely devoted to the major is-
sue of mandatory licensure for nurses in Missis-
sippi during the year. At the 101st Annual Ses-
sion, the House of Delegates received majority
and minority reports from the reference commit-
tee considering this matter. Neither was approved

202

JOURNAL MSMA

■

>r rejected, and the matter was recommitted to
rnr council by the House of Delegates.

The association was then confronted with a
fficult dilemma: The 1970 Regular Session of
e Legislature, before which the issue of man-
atory licensure for nurses was to be brought, was
> convene the first week of January 1970, and
ith great interests in patient care at stake, we
ad urgent need for policy clarification. Useful
ebate at the 101st Annual Session, valid opin-

1)n, and response from delegates were carefully
oted by the committee and council. Your coun-
il re-assigned this matter to the committee which
onducted meetings both with nurse organization
epresentatives and those of the hospital associa-
ion. Extensive deliberation in executive session
vas carried out.

The committee reported to your council which,
n turn, conducted a special meeting for consid-
ration of the issue. Taking note of the fact that
lurses have mandatory licensure in 42 of the 51
Jnited States jurisdictions and the fact that nine
Df 13 health service and health-related profes-
sions in Mississippi have mandatory licensure,
the committee viewed the problem in the con-
text of discussions before our House of Dele-
gates in 1969. Two points were primary:

— Whether mandatory licensure would serve
as an incentive for improvement in quality edu-
cation toward the end of better bedside nursing.

— Whether mandatory licensure would exacer-
bate the already-critical shortage of nurses.

The committee and your council were deeply
concerned over any threat to ( 1 ) medical as-
sistants to physicians who might not qualify for
licensure and (2) those employed in hospitals
who, while not carrying responsibilities of a
nurse in the literal sense, might be brought un-
der the law and be unable to qualify.

Accordingly, the following policy position was
recommended and approved by the council:

( 1 ) The association supports mandatory licen-
sure of nurses in principle, reserving the preroga-
tive of making further changes and improvement
(in the proposal), including the offering of
amendments to any bill introduced, and further
reserving to the Board of Trustees the prerogative
of final approval of any bill presented.

(2) The Committee on Nursing be utilized in
consultation and testimony before the Legislature
(within the framework of policy established) be-
cause of the committee’s familiarity and expertise
in the matter.

The Board of Trustees considered the work of
the committee and the recommendations of your
council in December 1969 and approved the pol-

icy. The committee chairman appeared as our
witness during hearings on the bill in the 1970
Regular Session. As this report is submitted, the
proposal is still pending, and the association con-
tinues to pursue its goals within the policy frame-
work established.

The chairman of the committee is Dr. Tom H.
Mitchell of Vicksburg, and there are five mem-
bers.

Health Insurance Benefits Advisory Commit-
tee (ad hoc). This committee continues to serve
as the official medical advisory committee for op-
eration of Medicare in Mississippi with official
status before the Certifying Unit for inpatient fa-
cilities, an activity of the State Board of Health.

The committee conducts meetings with physi-
cians experiencing problems under the program,
the Part 1-B carrier, the Part 1-A intermediary, in-
termediaries representing extended care facilities,
the Bureau of Health Insurance of the Social Se-
curity Administration, representatives of HEW,
and providers of services. The committee is not
encouraged over these conferences as to results
of its work and recommendations, despite its
sincere efforts and diligence.

An advisory panel of knowledgeable physicians
was appointed to work in utilization review as
regards hospitals and ECF’s, primarily with ref-
erence to the Certifying Unit, our third ad hoc
body.

The chairman of the committee is Dr. Mai S.
Riddell, Jr., of Winona, and there are seven mem-
bers.

Other Council Activities. Some small but en-
couraging progress is being made in placing prac-
ticing physicians as voting members of hospital
governing boards, despite opposition to this by
many hospitals. This useful and important means
of liaison with the medical staff bears the en-
dorsement of the Joint Commission on Accredi-
tation of Hospitals, the American Medical Asso-
ciation, the American College of Surgeons and
most major national specialty societies, our own
state medical associations and most of our sister
state medical associations.

We continue educational efforts and programs
designed to upgrade emergency medical ser-
vice. During the year, the helicopter demonstra-
tion project has shown great promise, as report-
ed in the Journal. Staffing of hospital emer-
gency rooms with physicians has greatly extend-
ed these services, and we endorse the various
approved postgraduate and continuing education
programs for physicians, nurses, and other allied
professional personnel in this area as being vital to
improvement of emergency medical services.

APRIL 1970

203

HOUSE OF DELEGATES / Continued

There is a salutary trend in legislative develop-
ment on standards for ambulance and driver
standards.

We met prior to the implementation of Title
XIX Medicaid with state officials of the Medicaid
Commission, and we have carefully monitored
program development. Oversight of program de-
velopment remained a primary responsibility of
the Board of Trustees during the year, because
of the Extraordinary Session of the Legislature to
shape the program. Your council, however, is
prepared to assume oversight of the ongoing pro-
gram when and if the Board and House of Dele-
gates so direct, as was the case in Medicare.

The council expresses appreciation to its sev-
eral committees, some of which are among the
most active bodies of the association, and to our
colleagues of the Board of Trustees who have
worked closely with us, giving understanding sup-
port and guidance to our problems and programs.
The council emphasizes to the House of Dele-
gates that its area of responsibility and concern,
the actual practice of medicine and delivery of
care, must have support from all members and
adequate staff in our Executive Office. We re-
pledge our best efforts in carrying out our work.

REPORT OF THE BOARD OF TRUSTEES

Organization and Duties. The Board of Trust-
ees is the executive and governing body of the
association during vacation of the House of Dele-
gates. It is additionally charged with the duties
and responsibilities prescribed by law for direc-
tors of corporations. In the discharge of these
duties, the Board shall have conducted six meet-
ings since the 101st Annual Session. The Board
met in May, September (having been forced to
cancel a scheduled August meeting because of
Hurricane Camille), December, and February.
Meetings are scheduled for April and May. Al-
together, these meetings included 10 meeting
days, usually exclusive of travel time.

Seven officers sit with the Board of Trustees
in all meetings. They are the president, presi-
dent-elect, secretary-treasurer, speaker, vice
speaker, and AMA delegates. The Board is as-
sisted in its work by support of the executive
staff. All 1969-70 meetings were conducted at
our headquarters building at Jackson.

This annual report includes actions on matters
referred to the Board by the House of Delegates
and those items relating to management and pol-
icy functions which are among the Board’s re-
sponsibilities.

Referrals from the House of Delegates. Mat
ters referred to the Board of Trustees by th<
House of Delegates at the 101st Annual Ses
sion and actions by the House requiring Boarc
action include:

(a) Blue Cross Group. The new hospital ser
vice contract available to the membership ha:
been operational for a year. It provides for 1 0C
days per confinement with a room allowance oi
$20 per day and all anciliary services. The House
of Delegates voted to have the Board ask the
plan to pay benefits due 15 subscribers in ar
amount of about $16,000 carved out undei
Medicare prior to concluding a nonduplication
agreement and to refer the matter of the non-
duplication agreement back to the Board for fur-
ther study.

The Board acted on the mandate of the House
on the payback, and the plan reports that this
has been accomplished. The matter of the non-
duplication agreement has become moot, since
the new 122X contract contains a standard pro-!
vision on this.

(b) Resolution No. 2. This resolution asks
that the association “seek amendments to exist-
ing law to provide for more proper and adequate
professional compensation” for autopsy. In ap-
proving the resolution, the House asked “that
the Board of Trustees of the association work out
a suitable fee schedule with the executive com-
mittee of the Mississippi Association of Patholo-
gists.” At the time of preparation of this report,
two bills to accomplish this are pending before
the 1970 Regular Session of the Legislature.

One measure would increase the fee from $75
to $250. While we sponsor and support the bill,
we have asked that the amendment provide for
payment of the usual and customary fee rather
than for a fixed amount. Prior to the convening
of the Legislature, conference was conducted
with the secretary of the Mississippi Association
of Pathologists, and a formal letter in this con-
nection was written inviting recommendations and
suggestions.

(c) Resolution No. 3. This resolution ex-
presses the belief of the association that “to re-
place physician-to-physician consultation with
physician-to-industrial firm consultation (in the
matter of laboratory services) would be unwise
and not in keeping with good medical practices.”

The resolution also asked that we communicate
our concern over advertisements (for commercial
or industrial laboratories) which appear in Jour-
nal AMA to the AMA House of Delegates. Drs.
Nelson and Hicks introduced an appropriate res-
olution at the 1 1 8th Annual Convention of

204

JOURNAL MSM A

AMA at New York. There were 10 similar reso-
lutions also introduced.

The AMA House, however, adopted a sub-
stitute resolution and a report of the Judicial
Council which, although reaffirming its historic
position on the practice of pathology being the
practice of medicine in every sense, took notice
of the court decree in the matter of United States
of America v. American College of Pathologists.
Under this position, nonmedical laboratory ad-
vertising is not barred from Journal AMA.

The Board of Trustees invites the attention of
the House of Delegates to the fact that nonmedi-
cal laboratory advertising is not accepted in our
Journal in the light of action at our 1969 an-
nual session.

1(d) Resolution No. 4. This resolution asks
that the Mississippi Medical Political Action
Committee prepare educational material concern-
ing the coronership and supply physician-candi-
dates suitable material coordination, and exper-
tise and that MPAC study the counties of the
state, encouraging physicians to seek this office.

The Board conferred with the chairman of
MPAC and found that funds of the organization
are extremely restricted. Moreover, these are the
only funds which may lawfully be used in can-
didate support. The PAC is not a formal orga-
nization in the sense of being able to sustain ser-
vice programs and studies. The Board, therefore,
offered the best resources available in accom-
plishing this purpose, the pages of our Journal,
and asked the sponsor of the resolution to sub-
mit materials for publication in furtherance of
the objectives which he sought in the resolution.

(e) Resolution No. 6. For the first time, in
1969 the House of Delegates approved the con-
cept of professional corporations for physicians.
This resolution called for our sponsoring an
amendment to Mississippi law in this connection.
An association-sponsored bill was introduced
early in the Regular Session, and we testified
three times in its support before the House Com-
mittee on the Judiciary. The measure passed the
House of Representatives without a dissenting
vote and is pending before the Senate Judiciary
Committee “A” at the time of preparation of
this report.

Nominations to State Board of Health. Follow-
ing up on House actions in 1969, nominations
were made to the Governor for appointment of
three members of the Mississippi State Board of
Health. These are:

For Public Health District 2: Drs. G. Lacey
Biles, Sumner; Julian C. Bramlett, Oxford; and
John R. Lovelace, Batesville.

For Public Health District 4: Drs. S. Lamar
Bailey, Kosciusko; Thomas N. Braddock, West
Point; and Lester D. Webb, Calhoun City.

For Public Health District 5: Drs. Lamar Ar-
rington, Meridian; John R. Laird, Union; and
Omar Simmons, Newton.

CHAMPUS. The association is in its 14th
year as fiscal administrator for the Civilian
Health and Medical Program of the Uniformed
Services (CHAMPUS), the original military Med-
icare. With amendments to the law providing out-
patient benefits and inclusion of retirees, the pro-
gram has grown fourfold into a multimillion dol-
lar operation. It remains unique in these re-
spects :

— It is the only medical care program in Mis-
sissippi operated exclusively under physician con-
trol.

— It is the only medical care plan with a vir-
tually unrestricted prescription drug program.

— It is unique in possessing a true usual and
customary fee reimbursement system under med-
ical peer control.

A five-member review committee meets 12 to
15 times annually on claims in question, and we
are paying about 94 out of every 100 claims ex-
actly as received. Our reorganized Department
of Medical Care Plans in our offices makes pay-
ment weekly to physicians and others providing
services.

Journal MSMA. Our Journal completed
its first decade of service to the association with
publication of the 120th consecutive monthly is-
sue in December 1969. This largest single asso-
ciation-sponsored project is a team effort among
the Editors, Committee on Publications, our
printers, and executive staff. The Board ex-
presses appreciation to the Editors and commit-
tee for their faithful and diligent services and
pledges continued support to this vital member-
ship service.

Legal Matter. At the 101st Annual Session, it
was reported that the association and the Execu-
tive Secretary had been named defendants in the
matter styled /. P. Culpepper, Jr., v. American
Medical Association. Also named as defendants
were the South Mississippi Medical Society and
two officers. AMA dues in transit through the
Mississippi State Medical Association in the
amount of about $31,000 were attached by the
plaintiff.

On June 9, the Executive Secretary answered
subpoenas for the association and himself in the
company of our legal counsel in Chancery Court
for Forrest County, when a continuance was or-
dered.

APRIL 1970

205

HOUSE OF DELEGATES / Continued

On July 8, the Chancellor, having accepted a
compromise which was also accepted by the plain-
tiff, dismissed the suit with full prejudice as Cause
No. 26509 on motion by plaintiff. AMA dues
funds in the hands of the “garnishee defendant,”
as the association was identified, were thereby
released. Because of the nature of the court or-
der, the matter is closed.

Insurance Programs. In addition to the Blue
Cross hospital group, the association also spon-
sors general accident, disability, health, and life
programs with the Continental Casualty Co.
through Thomas Yates and Co. of Jackson, ad-
ministrators, and a professional liability program
through the St. Paul Companies.

(a) Continental Programs. The group life pro-
gram, one of the most recently initiated, has been
successful to the point that benefits have been
increased by 20 per cent without change in pre-
mium. Where a member carries the previous
maximum of $40,000, he now has $48,000 for
the same premium. We have recently inaugurat-
ed a group ordinary life program which requires
no medical examination.

Participation continues to be excellent in the
disability income programs, catastrophic hospital
expense program, and office overhead expense
group. Approximately 40 per cent of the mem-
bership carry some 1,200 contracts in these pro-
grams. The administrator makes a full disclosure
reporting to the Board of Trustees on all aspects
of these programs. The association does not han-
dle any premiums or benefit payments, nor does
it realize any income from any insurance pro-
gram. We take the position that any profits which
might thereby accrue should be passed along to
participating members in the form of lower pre-
miums, increased benefits, or both.

(b) St. Paul Program. The association is in its
9th year with the St. Paul professional liability
program in which about 600 members partici-
pate. We have enjoyed the lowest professional
liability premium rate in the United States as a
result of our carefully managed program and
claims review counseling by the Board.

The professional liability crisis has become
acute in many states with astronomical premiums
ranging up to as much as $20,000 per year for
certain specialties. The Board urges that care and
diligence in the securing of this coverage be ex-
ercised and that threatened or instituted litiga-
tion be brought before the Board by any mem-
ber concerned. The frequency of suits has in-
creased as have awards and settlements in Mis-
sissippi.

Appointments. Under the provisions of Sec-
tion 1, Chapter VII, of the By-Laws, the ap-
pointive powers are vested in the President. Dur-
ing the 1969-70 association year, President
Royals has made the following appointments,
each of which has the endorsement of the Board
of Trustees:

(a) Alternate Delegate to AMA. Following
the death of Dr. B. B. O’Mara of Biloxi, his un-
expired term as Alternate Delegate to AMA was
filled by Dr. Joseph B. Rogers of Oxford, AMA
Alternate Delegate-elect.

(b) RMP Representative. President Royals,
upon assuming office, resigned as the association’s
member of the Regional Medical Program Ad-
visory Council. He appointed as his successor
Dr. C. D. Taylor, Jr., of Pass Christian, our im-
mediate past chairman of the Board of Trustees.

(c) Committee on Publications. This commit-
tee consists of the three Editors and three who
are appointed for terms of three years each by
the Board of Trustess. To serve the unexpired
term of the late Dr. B. B. O’Mara, President
Royals appointed Dr. Frank L. Butler, Jr., of
McComb.

(d) Delta-HEW Project. This program for a
five-county area, since identified as the County
Health Improvement Program (CHIP), is op-
erated by a Committee of Nine consisting of rep-
resentatives of the state medical association, the
State Board of Health, the University Medical
Center, the Mississippi Medical and Surgical As-
sociation, and consumer representatives. Dr.
Temple Ainsworth of Jackson, who represented
the association on the committee for two years,
resigned, and President Royals appointed Dr.
Lyne S. Gamble of Greenville as successor.

(e) Hospital Manpower Study. The Mississippi
Hospital Association received an RMP grant
with which to fund a manpower study. Dr. War-
ren N. Bell of Jackson was named to represent
the association as a member of the advisory body
to the project.

(f) Section on Preventive Medicine. When
Dr. Frank K. Tatum of Tupelo retired from the
practice of preventive medicine, he also resigned
as secretary of the Section on Preventive Medi-
cine of the Scientific Assembly. President Royals,
after consultation with the section chairman, ap-
pointed Dr. Frank M. Wiygul, Jr., to serve the
unexpired term as secretary of the section.

(g) Medicaid Committee. Upon invitation by
the Mississippi Medicaid Commission, President
Royals appointed a five-member Technical Ad-
visory Committee on Physicians Services. Mem-
bers are Drs. Joe S. Covington of Meridian (in-
ternal medicine) , James D. Hardy of Jackson (gen-

206

JOURNAL MSM A

eral and thoracic surgery), William J. Carr, Jr.,
of Gulfport (pediatrics), J. Leighton Pettis of
Tupelo (ophthalmology), and Tom H. Mitchell of
Vicksburg (general practice). The committee
elected Dr. Covington chairman, and he serves
as the association’s representative on the com-
mission’s Advisory Council.

Organization of the Board. One new Trustee,
Dr. James T. Thompson of Moss Point, District 9,
was welcomed to the Board during 1969-70,
bringing to a total six new Trustees named to
the Board since 1967. Dr. Thompson succeeded
Dr. C. D. Taylor, Jr., of Pass Christian who re-
tired after 13 years service, the last of which he
served as chairman.

Officers of the Board during 1969-70 are Drs.
Mai S. Riddell, Jr., of Winona, chairman; J. T.
Davis of Corinth, vice chairman; and William O.
Barnett of Jackson, secretary.

mediate prospect of improvement at Jackson, be-
cause the 300-room supermotel now under con-
struction is incapable of accommodating the meet-
ing.

Resolution No. 9. By tradition, the annual ses-
sion has been convened during the second full
week in May, thereby conflicting with Mother’s
Day and with municipal elections during years
held. Resolution No. 9 resolves “that the Board
of Trustees is empowered to alter the date of
the annual session so as to avoid these conflicts
and to make such changes as are necessary and
possible in contracts with the headquarters hotel
to accomplish this purpose.”

In implementing the resolution, the Board was
unable to alter the 1970 contract because of exist-
ing commitments by the hotel. We have, how-
ever, been able to make necessary changes for
1971 through 1973:

SUPPLEMENTAL REPORT “A” OF
THE BOARD OF TRUSTEES

Scheduling of Annual Sessions. The Constitu-
tion of the association provides for the annual
session, and under the By-Laws, it must be con-
ducted prior to the annual convention of AMA.
Section 2, Article V, of the Constitution states
that “the time and place for holding the annual
session shall be fixed by the House of Delegates,
but in emergencies, the Board of Trustees shall
have the power to fix or change either the time
or the place or both. . . .”

Since 1966, three major policy changes on
scheduling the annual session have been made
by the House of Delegates. Until 1966, the an-
nual session was scheduled on a year-to-year
basis, and by custom and tradition, it was ro-
tated between Jackson and Biloxi. Actually, these
have long been the only two cities in the state
with adequate facilities. Because of scheduling
difficulties on the year-to-year basis, the House
approved a four-year advance schedule, and the
association contracted on an alternating basis for
Jackson and Biloxi 1967-1970.

Site of Annual Session. As convention facilities
in Jackson became less satisfactory and as the an-
nual session grew in size and scope, it was noted
that attendance on the Coast was increasing. At
the same time, Coast hotel facilities were im-
proving as major hotels in Jackson were closed.

At the 99th Annual Session in 1967, the
House agreed that the 1968 meeting would be
conducted at Jackson to fulfill then-existing con-
tracts but that annual session thereafter would be
conducted on the Gulf Coast “until such time as
more adequate and suitable convention facilities
are made available at Jackson.” There is no im-

Annual Session

Dates

102nd
103rd
104th
105 th

May 11-14, 1970
May 3- 6, 1971
May 8-11, 1972
Apr. 30-May 3, 1973

To maintain our four-year advance schedule,
the Board of Trustees recommends that the 106th
Annual Session be conducted May 6-9, 1974, at
Biloxi.

SUPPLEMENTAL REPORT “B” OF
THE BOARD OF TRUSTEES

Hinder Report. In November 1965, the AMA
House of Delegates authorized and approved a
planning and development project through the
Board of Trustees who appointed an ad hoc
committee for this purpose. The committee re-
ported that AMA planning:

— Could be made more effective.

— That it should not be separated from man-
agement.

— That its process should be tailored to fit
AMA’s unique situation.

— Should be a commitment of leadership.

— Efforts should be to enlighten problems for
solution.

Recognition should be given to the fact that
the AMA structure presents severe limitations.

A Committee on Planning and Development
was appointed in 1968, chaired by Dr. George
Himler of New York. The report, a lengthy
document, was presented to the House of Dele-
gates at Denver in 1969, and a minority report
from Dr. John H. Budd of Ohio, a member of
the committee, accompanied the majority report.

The Himler Report is a searching and thought-
ful examination of medical care in the United
States, its manner of delivery, financing, gov-

APRIL 1970

207

HOUSE OF DELEGATES / Continued

ernmental influence, medical facilities, man-
power problems, allied professions, and the phy-
sician himself. It further touches on medical or-
ganization, health care consumers, and a host of
related areas.

The report contains 18 groups of recommenda-
tions totaling 57 in number. The minority report
contains 19 recommendations, each a modifica-
tion or refutation of a corresponding recommen-
dation in the majority report. As such, the mi-
nority report cannot stand alone as a substitute
for the majority report.

As should be expected of any major study of
this scope, challenge, depth, and candor dealing
with critical and painfully difficult problems, the
Himler Report has evoked controversy. As often
as not, opposition has been based on single state-
ments or groups of statements judged alone. Some
appear to object to the entire document as to con-
tent, but many of the recommendations flow
from existing AMA policy.

No attempt was made by the AMA House of
Delegates to act with finality on the report at
Denver, and indeed, they could not. The House
voted to name a committee to receive the re-
port, to study its content, and to refer it to the
governing bodies of constituent state medical as-
sociations.

In the latter connection, the AMA House stat-
ed that it can better act on the recommendations
“with the benefit of individual resolutions to be
submitted by the component and constituent state
associations or societies.” Your Board of Trustees
has reviewed the Himler Report and the minor-
ity report together with an analysis by our AMA
Delegates, Drs. Nelson and Hicks. They request
instructions on the wishes of the association, rec-
ognizing the magnitude of their tasks at the Chi-
cago annual convention of AMA in June.

The Board of Trustees recognizes the impor-
tance of this report and the difficulties implicit in
dealing with its recommendations. The Board
voted unanimously to transmit the report to our
House of Delegates and to publish it to the mem-
bership prior to our 102nd Annual Session, to-
gether with the minority report. The full text is
appended to this supplemental report, and the
Board hopes sincerely that every member of the
association will study it carefully and make his
wishes known.

President Royals has agreed to write every
member of the association and to invite attention
to this transmittal, asking for informed opinion
and debate.

The Board of Trustees encourages compo-
nent medical societies to generate resolutions and
policy positions on the majority and minority re-
ports herewith transmitted. We ask that indi-
vidual members of the association appear at the
reference committee hearing on this report and
discuss their views. We ask these things toward
the end of enabling our AMA Delegates to rep-
resent faithfully, accurately, and forcefully the
thinking of the association on this vital matter.

In making this transmittal, the Board also re-
cords the fact that it has conducted careful and
extensive deliberations over the majority and mi-
nority reports. Many points made have been con-
curred in, and many have not. Our present ob-
jective is to seek the widest possible participa-
tion in our decisions by the membership in an ef-
fective effort to advance the best thinking of our
association as a contribution to the delivery of
medical service in the United States.

REPORT OF THE AMA COMMITTEE
ON PLANNING AND DEVELOPMENT

In November 1965, the Board of Trustees of
the American Medical Association established a
Study Committee on Planning and Development
which was given the following tasks:

(1) To review and study current planning
procedures and techniques in the AMA for plan-
ning and development; and

(2) To study and recommend new mecha-
nisms and organizational arrangements to achieve
more effective planning and development for the
future.

The Study Committee, having completed its
investigations, summarized its recommendations
as follows:

( 1 ) The AMA can improve its effectiveness
by placing more emphasis on planning.

(2) The responsibility for planning should not
be separated from the responsibility for man-
aging the affairs of the Association.

(3) The planning process must be tailored to
fit the uniqueness of the AMA.

(4) The House of Delegates, the Board of
Trustees, all the councils and committees, and
the Executive Vice President and his staff must
make a significant commitment of time and other
resources in order to make the Association’s
planning more productive.

(5) A concerted effort should be made to
blend into the Association’s planning efforts the
knowledge and insights of many disciplines in-
cluding medicine, sociology, economics, law, and
any others which would bring more enlighten-
ment to bear on the problems facing the Associa-
tion.

208

JOURNAL MSM A

(6) The Association must recognize that its
present organizational structure does present se-
vere limitations and may have to be modified at
some future time.

The Study Committee went on to recommend
that “the AMA establish a permanent Committee
on Planning and Development,” and suggested
the objectives of the proposed committee and
how it might set about achieving the purposes for
which it was to be created.

To implement the recommendations in the re-
port of the Study Committee, the House of Dele-
gates, on the advice of the Board of Trustees, ap-
proved the establishment of a Committee on
Planning and Development. In due course, the
Board of Trustees appointed the committee and
gave it the following charge:

(1) To study and make recommendations
concerning the long range objectives of the As-
sociation and the resources, programs, and or-
ganizational structure by which the Association
attempts to reach them.

(2) To serve as a focal point for the planning
activities of the Association and stimulate and
coordinate planning activities throughout the As-
sociation.

(3) To study, or cause to be studied, medi-
cine and the environment in which the Associa-
tion must function and transmit the conclusion
of these studies, in the form of recommendations,
to the Board of Trustees for distribution to ap-
propriate decision making centers throughout the
Association, particularly the House of Delegates.

INITIAL STEPS

The first meeting, held on January 26, 1968,
was primarily organizational. The Committee re-
viewed the injunction it had received from the
House of Delegates and the Board of Trustees
and, after recovering from the shock of realizing
the magnitude of the responsibility, attempted to
break the task down into manageable parts.

It was agreed that the first step would be to
scrutinize the environment in which medicine is
now practiced, to identify current problems, and
to analyze the reasons for their development. In
addition to providing historical perspective, the
analysis was to be the substrate for short-term
policy recommendations.

Beyond this, the Committee thought it impor-
tant to identify current trends by studying the
forces that are influencing the practice of medi-
cine. The evaluation of these trends in terms of
their direction, vigor, and likelihood of endur-
ing was to provide the basis for predicting the
future form of medical practice and the social,
economic, political, scientific, and technological

climate in which it would probably be conducted.
The Committee also expected to use this study to
develop recommendations on how these trends
could be channeled, modified, supported or op-
posed in the best interest of the public and the
member physicians of the Association.

Finally a study of the structure and function
of the AMA was to indicate how well the orga-
nization is adapted to its presumptive future en-
vironment and what modifications, if any, will be
needed to prepare it to be effective under the
conditions that are anticipated.

From the sum of all the preceding observa-
tions, long-term recommendations on policy and
organization were to be formulated.

The most pressing problems that medicine and
the Association face are social, economic, legis-
lative, and legal in nature. The Committee there-
fore decided to direct its attention primarily to
these areas. Relatively little attention was given
to the scientific and educational activities of the
AMA except as they affect these more urgent
considerations. However, the scientific and edu-
cational functions of the AMA are of secondary
importance only in terms of immediacy, and
they may well be the subjects of future reports.

As a first step, the Committee familarized it-
self in detail with the structure of the AMA and
the operation of its administration and its coun-
cils, commissions and committees. Much written
material was made available by staff, of which
the Review Committee reports of 1967 were par-
ticularly useful. To supplement this information,
meetings were held with the Executive Vice
President, the Assistant Executive Vice President,
and the heads of the major divisions. The Com-
mittee’s purpose was to elicit from each what he
believed the long range objectives of his jurisdic-
tion to be, and what obstacles he saw to their at-
tainment, either within or outside of the organi-
zation.

As a last preliminary step, the Committee met
with a Committee of the Board of Trustees, com-
posed of Gerald D. Dorman, M.D., Chairman,
Joseph B. Copeland, M.D., and Burtis E. Mont-
gomery, M.D. The meeting was most helpful in
further refining the charge of the Committee and
outlining the scope of its endeavors.

BASIC CONSIDERATIONS

A few fundamental assumptions, decisions,
and policy determinations were necessary to
channel investigation and discussion along pro-
ductive lines. It is generally agreed that, since
medicine is a service profession, it cannot thrive
and prosper unless the needs of the public for
health services are fully met. Although recog-

APRIL 1970

209

HOUSE OF DELEGATES / Continued

nition of this principle is more or less implicit in
the “American Medical Association — Purposes
and Responsibilities,” it is not clearly stated. Peo-
ple must be made aware that the medical profes-
sion recognizes a community of interests with
them in maintaining the public health at the
highest level attainable.

The Committee therefore recommends:

( 1 ) That the AMA adopt the following as a
statement of the primary purpose and responsi-
bility of the Association and the medical profes-
sion:

“To endeavor, by all appropriate means, to
make health services of high quality available
to all individuals, in a dignified and acceptable
manner, regardless of their social class, ethnic
origin, ability to pay for services, or the
source of the payment.”

(2) The adoption of the following as a corol-
lary or, rewritten, as a separate policy state-
ment:

“The American Medical Association has the
duty to guide and assist the medical profession
in the attainment of this objective.”

On adoption, these statements should be
widely publicized.

The AMA has a second obligation which is
somewhat more subtle and therefore harder to
define. We are experiencing a soaring demand
for health services as a result of better public edu-
cation and more adequate funding for health
care from insurance and governmental sources.
This trend is augmented by the increasing com-
plexity of medical science and by our adoption
of progressively more stringent standards in judg-
ing the quality of professional services. It seems
almost certain that unless some fundamental
changes are made in the current system of de-
livering health care, the demand will outpace
our ability to meet it, regardless of efforts to train
additional personnel or build more facilities.
Therefore, if the total health establishment is to
meet the requirements and expectations of the
public, it becomes mandatory that the individual
professionals and the institutions that render
health services be more closely organized and at
a higher level than is now the case.

Some services require sophisticated equipment
that is found only in hospitals. Many types of care
necessitate a team approach that the solo practi-
tioner and his consultants cannot readily provide.

Considerations of convenience, economy, and
comprehensiveness will tend to force physicians
into one or more formal types of organization.
This may require attending physicians to share
authority and responsibility with other individu-
als and even institutions, thereby diminishing
their own. Partial transference will not only raise
the question of where the ultimate authority to
determine patient care lies, but will also tend to
weaken and depersonalize the relationships be-
tween physicians and their patients.

Given present social values, the encroachment
on physician-patient relationships will not be mas-
sive at first, since that would be resented by the
public and the medical profession alike. Never-
theless, some degree of curtailment of the time-
honored privileges, prerogatives, and authorities
of physicians are already upon us and further
encroachments seem inevitable if the public is to
get the health services it needs at a price that it
is able, or willing, to pay. To add to this picture,
there are already indications that rising costs may
bring about efforts on the part of government to
regulate or limit physicians’ fees, in an ill-ad-
vised effort to achieve economy.

It is generally agreed that independence in
thought and action and a high degree of intel-
lectual development are essential characteristics
for those who aspire to be competent physicians.
People of this caliber are likely to seek profes-
sions that, in addition to intellectual and personal
satisfaction, promise freedom from regimentation,
reasonably high standards of living, and ade-
quate compensation. The study of medicine is a
long and difficult discipline which must compete
with less demanding professions for a limited
number of qualified prospects. It can continue to
do so successfully only if, in addition to the great
personal satisfaction of medical practice, the so-
cial, financial, and intellectual rewards are suffi-
ciently attractive.

The AMA must therefore be continually so-
licitous about the setting in which medicine is
practiced and must attempt to maintain condi-
tions that will attract the best qualified and most
highly motivated individuals to the profession.
Every effort should be made to keep regulation,
restriction and regimentation to the absolute
minimum compatible with the Association’s
avowed purpose of helping to deliver health ser-
vices of high quality to all who need them. One
way in which the Association can move toward
this goal is to encourage and actively participate
in devising practice patterns and delivery systems
that are efficient, economical and non-restrictive
for both the provider and the consumer.

210

JOURNAL MSMA

The Committee therefore recommends:

That, while the AMA must be prepared to ac-
cept some circumscription of the traditional priv-
ileges and freedoms of physicians, the follow-
ing policy be adopted:

“That the American Medical Association
recognize the need for new and improved
methods of delivering health services, that it
encourage and participate in efforts to develop
them, and

“That, in the interest of attracting the most
highly qualified candidates to the field of medi-
cine, it simultaneously make every effort to
maintain and create incentives in medical prac-
tice. Among these incentives are minimal
regimentation, a multiplicity of practice op-
tions, and freedom of choice for both physi-
cians and patients.”

Adherence to these principles is not only in
the enlightened self-interest of the medical pro-
fession, but is in the public interest as well. All
other policy decisions of the Association should
be made in the light of these concepts.

At this point, two other decisions or assump-
tions had to be made, since they are fundamen-
tal to further recommendations made in this re-
port. The first of these was the adoption of a
definition of the term “health” since that defini-
tion will establish the dimensions of the health
care field in which the Association will function.
Many were considered and the one most in keep-
ing with enlightened social and medical philoso-
phy, in the Committee’s opinion, was that of the
World Health Organization.

The Committee therefore recommends:

That the AMA officially adopt the following
World Health Organization definition of health:

“Health is a state of complete physical,
mental and social well-being and not merely
the absence of disease or infirmity.”

Given this interpretation, health services in-
volve all aspects of man’s ecology and their
spectrum becomes much more extensive than the
mere provision of medical services. The question
then arises: How large a role should the AMA
claim in planning for the future and in develop-
ing systems for the achievement of the goals in
health care that were postulated earlier? The As-
sociation can follow one of three courses. It can
limit its efforts and interest to matters that are
purely medical and exhibit no concern for the
other elements that enter into the attainment of
the optimum degree of public health, such as edu-
cation, housing, environmental control, transpor-

tation, civil rights, and the alleviation of poverty.
Another alternative would be for the AMA to
concentrate primarily on the medical aspects of
health care but to show a continuing interest in
the above non-medical components of health
services. The final course would be for the AMA
to claim an active role in the planning and de-
velopment of all health plans and programs in all
their ramifications.

Clearly, the orderly and effective provision of
health services in the future and the planning and
implementation of health care programs will call
for multidisciplinary action and an unprecedented
degree of cooperation among the health profes-
sions. The AMA has neither the facilities nor the
personnel to undertake a regulatory and planning
function on this scale. Even if it did, it does not
have the authority to put the policies it might
develop into effect, nor does any other single
group, profession or association.

Nevertheless, there is now an almost total
lack of leadership in devising methods for im-
proving the utilization of our existing resources
of personnel, equipment, and funds. The equally
important problem of how to provide a progres-
sively increasing range of services as limitations
and shortages are overcome is also being ne-
glected, pending the slow and painful organiza-
tion of comprehensive areawide planning agen-
cies.

Public health officials have attempted to fill
this leadership vacuum, with but limited success.
Restraints on their authority and scope of activity
may have precluded their arriving at solutions for
issues of such protean nature. In any event, both
the interests of the public and th^se of the medi-
cal profession now require that the AMA and its
constituent societies become actively involved in
and endeavor to bring order and continuity to this
presently chaotic field.

The Committee therefore recommends:

That AMA adopt an active role and take the
initiative in developing all plans and programs
for health care in all their ramifications that
it encourage and assist state and county medical
societies to do the same at their respective levels.

The last recommendation, although necessary
at this point, is, of course, a generalization. The
specifics of how it may be implemented will be
suggested in succeeding sections. The foregoing
portion of this report outlines, in very general
terms, the range of interests and the scope of ac-
tivities the AMA should assume to play an ef-
fective part both in the revolution that is cur-
rently sweeping medicine and in the era of sys-
tematic progress that, hopefully, will follow.

APRIL 1970

211

HOUSE OF DELEGATES / Continued

EVALUATION OF CURRENT TRENDS

In order to evaluate the trends that are now
affecting medical practice and those that may af-
fect it in the future, it is necessary to understand
the public’s attitude toward government and to-
ward social programs supported by tax funds.

Perhaps the most obvious and striking change
in public psychology since the end of World War
II, and more particularly in the past decade, has
been a great increase in expectation. The people
expect better housing, education, environmental
conditions, transportation, and health services.
The problems involved in improving facilities
and services in these categories are so complex
and interrelated that simultaneous solutions cov-
ering broad geographic areas are often needed.
In addition, since the programs must be massive,
the costs are correspondingly great. As a result,
local voluntary agencies, professional associa-
tions, management, labor, and all other groups
and organizations comprising the private sector
discovered that they have neither the funds nor
the authority to plan and implement the pro-
grams that are required if public aspirations are
to be met. Local and municipal governments
found themselves similarly limited and turned to
their states for financial support. The latter, hard
pressed as they are for funds, have sought help
from the federal government.

In response to these appeals from lower
echelons of government and inspired by the pub-
lic clamor for better living conditions, more and
better services, and greater security, Congress
created a number of social welfare programs.
There are those who will argue that the demand
for these was not spontaneous but was deliber-
ately aroused and nurtured by those in govern-
ment whose political philosophies incline toward
the creation of a paternalistic, or even a social-
ist, state. There may be some truth in this be-
lief, but it is idle to speculate on where the rise
in expectations originated. The fact is that the
public appetite has been whetted and, more sig-
nificantly, that the majority of the people look to
government for its satisfaction. They will sup-
port, or at least not oppose, the expenditure of
large sums of tax money on broad programs for
social welfare. As time goes on, this attitude
will become progressively more important as a
determinant of public policy. The mere existence
of the poverty program and of new and ex-
panded grants-in-aid for transportation, housing,
education, research, hospital construction, and
health services represents a concrete though un-
expressed decision on the part of the federal gov-

ernment to intervene more directly in the lives
of Americans by guaranteeing them many ser-
vices and commodities that they hitherto were
expected to provide for themselves. Although the
involvement of the United States in extra-terri-
torial military operations, foreign aid, and other
commitments of money and manpower have lim-
ited the scope of some of these plans, the limita-
tion is likely to be temporary. The principle has
taken root, and as this country’s external obli-
gations diminish or its exuberant economy yields
greater tax income, old programs will be expand-
ed and new ones will be established.

This trend will be curbed only by the refusal
of a sufficiently large portion of the population
to be taxed for services they do not individually
need. However, since most of the social legisla-
tion enacted to date has been poverty oriented
and represents aid to the needy and underpriv-
ileged, this type of resistance is only now be-
coming evident. The short term endpoint of fed-
eral, state and local government activity in the
area of social welfare in unpredictable. Never-
theless, it is safe to say that unless the private
sector can propose effective solutions to existing
problems, the next decade will see us moving in
the direction of vastly broadened assumption of
authority and responsibility by government, with
a concomitant increase in public dependence on
assistance programs.

Ironically, the organization necessary to satisfy
the newly aroused public impatience for better
living conditions, more government guarantees,
and greater security is almost totally lacking.
Most federal government programs of recent vin-
tage, since they were created in response to pres-
sure or crisis, were hastily enacted with insuffi-
cient regard for their cost or their feasibility in
terms of facilities, administrative mechanisms,
and professional manpower. In addition, partly
because differences in local conditions, needs,
and facilities dictated that planning begin on a
local level, partly out of deference to states’
rights, and partly because central administration
of massive new programs was not immediately
practical, recent social welfare laws have been
limited by Congress to the provision of grants-
in-aid or matching funds. Implementation of the
programs has been left to the states within fairly
loose frameworks of conditions, standards, and
criteria. Usually, to stimulate the states into
prompt compliance, the laws set time limitations
on program activation. Most states, anxious not
to lose their share of federal largesse, passed
hasty, and often ill-conceived, implementing leg-
islation and then placed their reliance on local
and municipal governments to put the programs

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into operation. The resulting confusion has seri-
ously impaired the new programs and has brought
about frictions and damaging waste of limited
human and financial resources. In the general
confusion, state and local legislators, administra-
tors, and a new corps of government advisors
have busily elaborated a great variety of favorite
theories, plans and procedures, which, when
translated into action, have proved to be costly
and ineffective.

If our present social and political climate had
to be described in a few words, it would be
characterized by high aspirations, poor organiza-
tion for achieving them, great but finite national
wealth, high and rapidly rising costs, and an al-
most total absence of the comprehension needed
to solve complex and interdigitating social prob-
lems. Nevertheless, those problems must be over-
come, and the new laws, despite their glaring
deficiencies, constitute at least a primordial soup,
containing all the ingredients necessary for the
generation of viable programs if only the proper
catalysts can be found. Those catalysts are lead-
ership and cooperation.

Clearly, the problems in the field of health
alone, in their entirety, are beyond the influence
and competence of the AMA to solve without as-
sistance. Nevertheless, if the AMA were to take
the initiative in devising plans for the improved
organization and delivery of health services, it
would not only be contributing to the attainment
of its stated objectives relating to public health,
but would also be leading the way to effective
action in other fields. Specific recommendations
to that end will be made later in this report.

RECENT LEGISLATION: EFFECTS ON
HEALTH CARE AND IMPLICATIONS
FOR THE MEDICAL PROFESSION

Having considered the general characteristics
of social welfare legislation, let us turn to the
examination of recent laws that have profound
implications specifically for the practice of medi-
cine.

Public Law 89-97 established Medicare and
Medicaid. It has since been amended only in rel-
atively unimportant details. Title 18 of the law
establishes hospital and health service benefits for
those over 65 years of age. Title 19 provides fed-
eral matching funds to encourage the states to
create programs for the ultimate provision of a
broad spectrum of health services to the indigent.

In its entirety, PL 89-97 has already had a
protean effect on medical practice although its
full impact is not yet generally appreciated.

Public Law 89-239, the so-called ‘'Heart Dis-
ease, Cancer, and Stroke” law, is concerned with

hastening the diffusion of the knowledge gained
from abstract and clinical research from the med-
ical centers to the practitioners who are in inti-
mate and daily contact with patients.

Public Law 89-749, the “Partnership for Health
Amendments to the Public Health Service Act,”
was subsequently amended by PL 90-174. The
law is directed toward creating agencies for area-
wide, comprehensive health planning at the local,
regional, and state levels. It is now only in its
early organizational phases but will increase in
importance as planning agencies are activated.

It is beyond the scope of this report to go into
the details of these laws since they constitute a
study in themselves. Suffice it to say, however,
that, either implicitly or as they have been im-
plemented, they firmly establish the following
concepts as public policy:

(1) Every citizen has the right to the health
services he needs.

(2) The services he receives must be of high
quality and readily available.

(3) The responsibility for the quality and
availability rests with the agency administering
the program.

(4) Health services of high quality are de-
fined as services that are “comprehensive,” “pa-
tient-oriented,” or represent a “continuum of ser-
vices,” in contradistinction to “episodic,” or “dis-
ease-oriented,” as our present system is alleged
to be.

(5) Government, when necessary, will pay for
health services either from the premiums of so-
cial insurance as it does in Medicare, or from
general tax funds, as it does in the Medicaid
program.

If we examine these concepts, each of them
brings a number of questions and problems in its
wake.

ABRUPTLY INCREASED DEMAND FOR

HEALTH SERVICES

The thesis that every human being has a right
to all needed health services is disarmingly sim-
ple and is now generally accepted. The fact re-
mains that in the past one either paid for medical
services or received them from government. In
the latter case, the indignities of welfare process-
ing and the frequently low quality of care were
powerful deterrents to utilization. These deter-
rents have almost disappeared and, while no one
mourns their passing, it is evident that their re-
moval, coupled with more widespread health ed-
ucation, is creating an insatiable demand for
health services, far in excess of that experienced
when self-pay, insurance, or welfare allowances
were the only sources of reimbursement for them.

APRIL 1970

213

HOUSE OF DELEGATES / Continued

SHORTAGES IN ALL CATEGORIES OF

HEALTH SERVICE

The increase in demand has been more than
the health professions and the voluntary, proprie-
tary, and government hospital systems could
meet. A dismaying shortage of medical and para-
medical personnel has become increasingly ap-
parent.

Absolute Shortage of Physicians: The overall
scarcity can be alleviated by increasing training
capacity and efforts are being made to do that.
The AMA has very properly supported greater
registration at existing medical schools and the
founding of new ones. This encouragement, de-
signed to increase the output of physicians,
should, of course, continue. The Association
should also continue to explore the possibilities
of shortening the total duration of medical edu-
cation by a judicious combination of college and
medical school curricula, lengthening of the aca-
demic year at the expense of vacation time, and
specializing undergraduate education to corre-
spond more closely to the specific field chosen by
the student.

In the area of graduate education, considera-
tion should be given to the shortening of resi-
dency requirements for specialty board certifica-
tion since there is reason to believe that the ab-
breviation need not adversely affect the quality
of training.

Area Specific Shortages of Physicians and Oth-
er Health Professionals — The Slums: If across-
the-board scarcity were the full extent of the
manpower problem, its solution would be rela-
tively simple by the use of the above expedients,
although there would necessarily be a few years
of lag time before the effect of increasing training
capacity became appreciable. Unfortunately, it is
evident that there will be a continuing shortage
of health care personnel for some segments of the
population regardless of the total supply. The
poor and underprivileged who inhabit the urban
slums and ghettos are most deprived of essential
health services and are least likely to receive
adequate care in the near future.

It would be too facile to assume that they lack
health care simply because they cannot pay phy-
sicians and other health professionals, and that
the latter, for that reason, do not establish prac-
tices in their communities. If that were true, gov-
ernment subsidy of their health care would even
now be mitigating the shortage. The poverty
pockets are unattractive to health professionals
for other reasons. They are characterized by a

high degree of racial tension, by lack of respect
for private property, and by periodic outbursts of
violence. To complete the picture, the few phy-
sicians who practice in such localities are subject
to abnormally heavy workloads, poor compensa-
tion for the services they render, inadequate hos-
pital facilities, and lack of assistance. Under these
circumstances, the penalties of practice far out-
weigh the few rewards, and it is small wonder
that there is an intolerable shortage of health
manpower in these neighborhoods.

But the deficiencies of care for the underpriv-
ileged are not the most important reason for
their generally poor state of health. Poor nu-
trition, inadequate housing, lack of education
with its attendant joblessness, and the frustrations
of adverse discrimination and segregation are
probably much more important as causative
agents. The correction of these inequities is a
social rather than a medical problem. It depends
on ethnic and racial adjustments which will re-
quire almost infinite cooperation, patience, and
mutual understanding. Unfortunately, these com-
modities, like everything else, are currently in
short supply. The final remedy for the health
care ills of the ghettos will be the elimination of
the influences that make them what they are.
Although the medical profession has neither the
capacity nor the responsibility to resolve these
larger issues, it must be prepared to take an ac-
tive part in doing so. The deficiencies, however,
are too pressing to await the beneficial effects of
long term planning, education, and racial and
ethnic accommodation. Substantial numbers of
health personnel are needed urgently.

Clinics financed by the Office of Economic
Opportunity have as yet done little to meet this
need. Relatively few groups have been estab-
lished and, if complaints from a number of local
medical societies are accurate, not all of these are
in the deprived areas for which this type of fed-
eral financial support was intended.

Interestingly enough, there is no unanimity of
opinion that the OEO concept of hospital-based
multispecialty clinics is the answer to the health
care problems of the slums. The National Medi-
cal Association, comprised largely of Negro phy-
sicians, many of whom have an intimate knowl-
edge of the people and the unique needs and
characteristics of the poverty areas, does not be-
lieve that it is. Health services, if they are to be
effective, must not only be available, they must
be acceptable to those for whom they are in-
tended. There is some question whether the med-
ical schools and centers that dominate the OEO
clinics are attuned to the nuances of the manner
in which health services must be offered in poor

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JOURNAL MSM A

communities. The cultural determinants of the
utilization of health services are poorly under-
stood by most medical center faculties and staffs.
The NMA makes the point that more of the care
should be rendered by physicians who have their
origin and roots in the underprivileged areas and
represent predominant ethnic or racial groups.
This would not only result in better mutual un-
derstanding between patients and physicians but
would also permit the self-sustaining to seek their
health services from the same source and under
the same conditions as do the indigent.

Historically, the health needs of the ghettos
have been left to the voluntary and municipal
hospitals and government at various levels to
meet, while private practice excluded itself as a
delivery mechanism. The belief has been grow-
ing among legislators and public officials that if
hospital-based, closed panel clinics are most ef-
fective in meeting the requirements of the poor,
they are equally applicable to other segments of
the population. The obvious fallacy of this be-
lief does not diminish the danger it poses to pri-
vate solo and group practice as government pays
an ever increasing portion of the national bill for
health services.

It is therefore essential that the medical profes-
sion at least attempt to meet the medical care
needs of the ghettos in the context of individual
or private group practice with freedom of choice
for both physicians and patients. If such an at-
tempt is to be successful, financial assistance must
be secured for physicians who are willing to
establish group practices in these areas and who
present organizational plans that assure a high
quality, variety, and continuity of care. Such as-
sistance, if not available from the Office of Eco-
nomic Opportunity with its known penchant for
hospital-based practice, might be available under
the provisions of PL 89-754, which amends the
National Housing Act to permit the Secretary of
Housing and Urban Development to insure
mortgages for the construction of facilities for
medical practice groups.

Community leaders will have to cooperate by
providing police protection necessary to permit
the free movement of personnel. They may also
be called on to devise financial incentives of vari-
ous types to attract physicians to their areas.

If no physicians can be found who are willing
to devote their full time to practice in under-
privileged areas, there may be some who would
practice in groups on a part-time, rotating basis
given the proper incentives and technical assist-
ance in structuring and financing their groups.

None of these expedients will fully rectify
present conditions, but a beginning must be made.

It must be recognized that from a purely ad-
ministrative point of view closed-panel, prepaid
practice offers advantages to government. This
type of practice may become the major or sole de-
livery system for government-supported pro-
grams if the privately practicing sector of the
medical profession does not rise to the occasion
by providing demonstrably superior care to the
underprivileged. The proliferation of such pro-
grams would subject medicine to ever increasing
regimentation and government control.

It should be noted that only a very small per-
centage of medical students are drawn from low
income families and the underprivileged areas. It
might be a practical expedient to select properly
motivated, intelligent individuals from these back-
grounds and finance their medical education, in
the hope that they would return to practice med-
icine in the areas from which they came. An-
other, and less attractive possibility would be to
require such physicians to practice in certain
areas in facilities provided for them for a speci-
fied period of time, as a quid pro quo for the
assistance they have received. This is commonly
done in poor countries, in Latin America and
elsewhere where the purely voluntary distribu-
tion of physicians would leave large gaps in
medical services.

Area Specific Shortages of Physicians and Oth-
er Health Professionals — Rural Communities:
The problems of the rural communities have
some similarity to those of the poverty pockets.
Again, heavy patient loads and poor reimburse-
ment are often factors. In addition, the rural
environment is unattractive to most young phy-
sicians and their families. They find it deficient
in opportunity to engage in social and cultural
activities, to educate their children, and to find
entertainment. Rural practice generally does not
afford the physician either the time or the fa-
cilities to continue his own professional educa-
tion, and young physicians, in choosing a site to
practice, are reluctant to forego the intellectual
stimulation they experienced at the medical cen-
ters in which they trained. The relative impor-
tance of these factors varies with the individual
and the location but it is evident that as the older
MD’s die in rural communities, they are replaced
with great difficulty or not at all.

In this situation, again, some answers may be
found in the development of inducements to at-
tract physicians to the rural areas. Similar ef-
forts, usually made by the communities them-
selves, have not been notably successful in the
past but it is entirely possible that with state and
local medical society assistance, more effective
programs for recruitment can be devised. This is

APRIL 1970

215

HOUSE OF DELEGATES / Continued

important because, while rapid transportation of
patients to urban centers may compensate for
some of the deficiencies of rural health care,
there is ultimately no substitute for the day-by-
day services rendered by the local physician.

The Committee therefore recommends:

( 1 ) That an appropriate committee or divi-
sion of the Association secure data from all the
state medical societies on the adequacy of health
services and the manner in which they are being
provided in their rural and underprivileged areas,
and the practice mechanisms, if any, that are
being considered or developed to correct existing
deficiencies. Based on this information, the same
committee should devise delivery systems con-
sonant with the Association’s principles and in-
centives for physicians to settle in medically de-
prived localities.

(2) That the Association, in conjunction with
state and county medical societies, establish a
service of consultation and assistance for such
physicians to facilitate the planning and financ-
ing of their projects.

(3) That, in those instances in which phy-
sicians cannot be found to develop health care
facilities with the capability of providing needed
services, the AMA urge, encourage, and assist
the state and local medical societies to do so on
an operational basis.

(4) That the Association study the possibility
of establishing a corporation for this purpose,
with subsidiary corporations at state and local
levels. All such corporations should be legally
empowered to receive payments for services
rendered and would apply surplus income over
expenditures to activities designed to improve
health care in their areas, both quantitatively and
qualitatively.

(5) That the AMA and the constituent and
component medical societies seek the active in-
volvement of medical centers and voluntary
hospitals in health service projects for the med-
ically underprivileged.

The Committee emphasizes that the provision
of health services in rural areas and in poverty
zones must not be abandoned to the government
by default.

SHORTAGES OF SPECIFIC CATEGORIES
OF HEALTH PERSONNEL BY
PROFESSION AND SPECIALTY

To consider further the matter of medical man-
power, the short supply of generalists or family
physicians represents another major deficiency.
Again, new incentives must be created to reverse
the inexorable diminution of those who, in addi-

tion to providing basic care, serve the important
function of coordinating medical services for their
patients. Not the least of these new attractions
would be the assurance of a higher professional
standing than these physicians have enjoyed in
the past and the admission of generalists into
hospital practice on an equal prestige footing
with the specialists. The Association has moved
in this direction by recognizing family practice as
a specialty. This action, coupled with widespread
establishment of general practice sections in hos-
pitals, could slow or reverse the trend away from
general practice. These questions have been dis-
cussed at such length in medical circles that they
hardly require further elaboration in this report.

The Association’s public pronouncements on
manpower deficiencies to date have emphasized
the general shortage of health personnel and
have highlighted suggestions and efforts to in-
crease training facilities and enrollment. This is
an oversimplification since these measures alone
will not suffice to overcome current deficits and
meet new demands. When this fact becomes ap-
parent, the AMA will again be criticized for hav-
ing failed to recognize the true dimensions of the
problem.

The Committee therefore recommends:

(1) That the AMA, through its Council on
Health Manpower, in conjunction with other pro-
fessional, educational, and lay associations, con-
tinue to explore and develop expedients to over-
come health manpower shortages.

(2) That the Association, in its future dec-
larations and activities directed toward the al-
leviation of shortages in health services and per-
sonnel, underscore the fact that these shortages
are not due merely to an insufficient number of
health professionals across-the-board, and em-
phasize that maldistribution of practitioners geo-
graphically, by profession, and by specialty is an
equally important factor in depriving communities
of an adequate supply and spectrum of health
services.

(3) That the Association publicize the reasons
for the maldistribution, as outlined in this sec-
tion, and stress that the voluntary correction of
these deficiencies requires public cooperation and
community action in addition to the measures
taken by the health professions.

The limitations of the service capacity of the
health professions will be a matter of increasing
concern for the public as well as the professions.
Overcoming relative and absolute manpower
shortages will take time, possibly a decade or
more. During this time, the demand for health
services will multiply as the population grows,
urbanization and personal incomes increase, the

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JOURNAL MSMA

proportion of the aged rises, health education is
more widely disseminated, and more govern-
ment funds are allocated for health programs.
This trend will aggravate the present dispropor-
tion between the supply of health professionals
and the increasing demand for their services.
Any reasonable device must therefore be ex-
plored to conserve the time of overworked phy-
sicians. One expedient would be to limit the ser-
vices they perform to those that require the ex-
ercise of their special skills.

Use of “Doctors’ Assistants” to Augment Med-
ical Service Capacity: One proposal designed to
stretch the service capacity of the medical profes-
sion with the present supply of physicians has
been that less highly trained individuals be spe-
cifically educated and utilized to perform rou-
tine examinations and treatments. Several experi-
ments in the training and use of doctors’ assist-
ants are now in progress. The University of Colo-
rado is conducting a project for training regis-
tered nurses to do some procedures in pediatric
practice, particularly well-baby and routine care.
The plan operating at Duke University is in-
tended to train modern and improved versions
of army medical corpsmen. In a number of
areas, proposals have been made to revive the
use of nurse-midwives for uncomplicated obstet-
rics. Many pursuasive arguments have been ad-
vanced in support of utilizing personnel with a
medium level of training to relieve the pressures
on more highly skilled physicians and thereby
meet the demand for services. To a limited de-
gree, and in chosen localities, this device may in-
deed be necessary and useful. The entire con-
cept, however, is heavily booby-trapped and be-
fore it is enthusiastically adopted by the medical
profession, some caveats are in order.

Physicians who are too busy to render com-
plete medical care to their patients may well be
too busy to supervise the services rendered by
their assistants. This could result in a significant
deterioration of services. Furthermore, since the
legal responsibility for patients rests with their
physicians, the use of assistants on a large scale
opens a wide and unappetizing vista of ever in-
creasing malpractice litigation. Another and rath-
er obvious disadvantage of employing assistants
in this new and expanded sense is that it would
further depersonalize medical care precisely when
the profession, to preserve some of the positive
values of current medical practice methods, is
endeavoring to strengthen the personal relation-
ship between physicians and their patients.

This expedient, if generally adopted, would be
applied to a great number of specialties and
would result in the creation of a number of sub-

professions which would be a nightmare to li-
cense, limit, audit and supervise. Understand-
ably, but inevitably, the new assistant groups
would seek to widen the permissible scope of
their services and to increase their responsibility,
authority, remuneration, and independence of
action. This could seriously compromise physi-
cians’ responsibility for the care of their patients,
and materially increase the cost of that care. The
medical profession must not fall into the error
of accepting the principle of creating corps of
“doctors’ assistants” except with stringent safe-
guards and provision for their close supervision.

The Committee recognizes that the productiv-
ity of physicians must be increased if shortages
in health care are to be overcome, and that one
method of doing so is to utilize the services of
doctors’ assistants. While not wishing to discour-
age the adoption of this general principle, the
Committee reemphasizes the need for appropri-
ate guidelines and safeguards.

The Committee therefore recommends:

( 1 ) That an appropriate Committee of the
AMA immediately begin to formulate a policy
on doctors’ assistants, particularly with regard to
their responsibilities, limitations on their practice,
and supervision of their services by qualified
physicians.

(2) That the AMA reaffirm the principle that
the basic responsibility for the care and welfare
of patients lies with their physicians of record
and that that responsibility cannot and should
not be delegated.

(3) That the Association’s Law Division assist
the state medical societies in identifying and
avoiding any legal hazards that may accompany
the employment of doctors’ assistants.

DELIVERY SYSTEMS FOR HEALTH CARE

Partly because of manpower deficits and part-
ly because of the rapidly rising costs of health
care, the Department of Health, Education, and
Welfare has exhibited a keen interest in delivery
mechanisms for health services. A National Cen-
ter for Health Service Research and Development
has been created in the department. The center,
not yet in full operation, will conduct field studies
to evaluate programs in being, develop pilot
projects and demonstration programs, and gather
data on all known methods of providing health
services. Ultimately its recommendations will
probably establish HEW policy on the programs
under its jurisdiction. Ideally, the center will ac-
cumulate detailed information on the effective-
ness, cost, and acceptability by the public of
various health service mechanisms and make ob-
jective recommendations based on that informa-

APRIL 1970

217

HOUSE OF DELEGATES / Continued

tion. indications are that the major focus of its
interest will be group practice.

In many ways that need not be enumerated
here, group practice, as compared to solo prac-
tice, has substantial advantages for both physi-
cians and patients. As a result, the percentages
of physicians engaged in private, fee-for-ser-
vice, group practice has been rising steadily.
Most groups are of the multispecialty type and
offer a reasonably broad range of services. Less
commonly, they are composed of physicians in a
single specialty. Characteristically, they are re-
imbursed on a fee-for-service basis and all the
members are partners, which gives them a direct
stake in maintaining high standards.

The other main type is the so-called closed
panel group which accepts patients for all the
care they may need on a prepaid, capitation ba-
sis rather than fee-for-service. This requires the
interposition of an insurance carrier between the
patients and the providers of service. In some
instances the physicians are partners in the group
but the majority are employed on either salary
or per-session payments.

The major exponents of this arrangement are
the Health Insurance Plan of Greater New York
in the east, and Kaiser-Permanente Plan on the
west coast. In addition to the advantages of group
practice in general, both have claimed lower hos-
pital utilization and morbidity rates than are ex-
perienced in insured groups that have a reim-
bursement type of health insurance and pay fee-
for-service. They attribute these claims to more
effective preventive care and treatment, but such
claims, of course, are almost impossible to sub-
stantiate. It can be argued, for instance, that low
rates of hospital admission and short duration of
stay may well represent inadequate rather than
optimum utilization. Morbidity rates are difficult
to compare because of the differences inherent in
the two systems. The patients of a prepayment
group are largely members of a consumer orga-
nization of one type or another. In the majority
of instances, the contract is negotiated between
an insurance company distinct from the medical
group and a labor union or other consumer agen-
cy. The patients resulting from this type of se-
lection often have group characteristics that in-
validate comparison with the randomly selected
clientele of fee-for-service individual or private
group practice. In addition, the differences in the
manner in which the two systems render services
and the tendency of patients of a prepayment
group to seek the services of a personal physi-

cian outside the group for grave illnesses makes
the comparison of statistics very misleading.

Aside from these considerations, closed panel,
prepaid practice has several definite disadvan-
tages for patients. Once families or individuals
have enrolled in a plan that provides this type of
care, they have lost the right to choose their own
physician. In theory, they can select any mem-
ber of the group, but the actual choice is almost
nil because of the relatively small numbers of
physicians in the groups and their limited avail-
ability. The patient’s freedom to join another
group in the same plan is hypothetical rather
than actual since distance and convenience al-
most forbid such transfers. Those patients who
want treatment or consultation outside the plan
must pay a penalty for doing so since there is no
provision for reimbursing them for their expendi-
tures.

Whatever the reasons, insurance programs
based on closed panel practice have not been re-
motely comparable in growth to those that pay
fee-for-service benefits and allow free choice of
physician, in spite of the fact that the former of-
fer a complete spectrum of care while the latter
have varying limitations, exclusions and co-pay
features. There must therefore be some element
in closed panel practice that militates against its
general and enthusiastic acceptance by the pub-
lic.

The Committee does not propose to advocate
any particular type of practice. It is disquiet-
ing, however, to learn that, after establishing a
center supposedly intended to evaluate the vari-
ous systems, high officials of HEW have already
reached their own conclusions and openly favor
prepaid health care delivered by closed panel
groups. They are probably influenced by the ease
with which the distribution of personnel and the
range of services can be controlled in closed panel
practice. In addition, cost control, via negotiation
for capitation rates, is certainly simpler and
more predictable than it is with the usual, cus-
tomary, prevailing, and reasonable method of re-
imbursement (hereafter abbreviated to UCPR).
In spite of the simplicity in negotiating and
predicting costs in the prepaid group practice sys-
tem, however, the cost economies such groups
claim have yet to be proven. Whatever the rea-
sons, the attitude of the officials of HEW is the
antithesis of the impartial analysis and objective
decision that were hoped for and that are neces-
sary to determine the relative merits of the dif-
ferent practice mechanisms. This type of preju-
dice could not only result in costly and harmful
errors in the administration of tax supported

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JOURNAL MSM A

programs, but could affect the private sector ad-
versely.

The House of Delegates, at the 1968 Annual
Convention, recognized this and adopted a reso-
lution that “The AMA strongly disapproves the
provision of funds by the federal government for
subsidizing any one form of organization of medi-
ical practice.” Unfortunately, the same resolution
went on to state, “Resolved, That the AMA con-
tinue to espouse the private, fee-for-service prac-
tice of medicine.” It is hardly logical for the As-
sociation to call for objective experimentation in
the organization of medical services and in the
same breath to express its preference for private,
fee-for-service practice. It is equally inconsistent
to call the Department of HEW to task for giving
preferential support to one form of medical prac-
tice and simultaneously express the Association’s
prejudice for another.

It is well to remember that the Association
represents members who are engaged in all types
of medical practice and that they must be repre-
sented impartially. Furthermore, there are many
possible variations and combinations of solo prac-
tice, fee-for-service group practice, prepaid capi-
tation practice and even physician employment
that may be useful in providing care under cer-
tain circumstances. Combinations of fee-for-ser-
vice payment and prepayment are also possible.
It is well known, for instance, that one of the ma-
jor obstacles to the development of voluntary in-
surance coverage for out-of-hospital services has
been the prohibitively high cost of processing
large numbers of small claims. In many cases the
processing cost is almost equal to the payment,
which almost prevents such services from being
insurable and which may in part be responsible
for the high cost of Medicare. One possibility for
overcoming this disadvantage is to establish a pre-
paid pool on which physicians, individually or in
groups, could draw for certain types of individual
services, thereby eliminating the costly process-
ing of small claims. Fee-for-service payments
could be retained for larger and more readily
identifiable items of care. Similarly, it is possible
that pediatricians would accept capitation fees
for well-baby care while retaining fee-for-ser-
vice for the balance of their practice. The Com-
mittee does not wish to suggest specific types of
organization or payment. It merely wishes to
point out that there are many possible combina-
tions and permutations that may be useful in
the future and that the Association should not be
on record as being opposed to any of them until
they have been fairly tried.

The immediate needs to be met are enormous

and are creating proportionate pressures. The
virtually uncontrollable rise in the public’s bill
for health care will dictate the most stringent
evaluations of cost effectiveness. Under these cir-
cumstances, all varieties of organization for
health care and many methods of payment will
be put to the test of competition regardless of the
position the Association may take. Rather than
support particular kinds of organization and pay-
ment for health services and oppose others, the
AMA should devote its energies to establishing
the criteria by which they are judged. These
standards should transcend the mere logistics of
delivery and the cost of care. They should in-
clude considerations of the quality of care, the
dignity of the circumstances under which it is
provided, and the choice of options that the plan
allows for providers and consumers.

The Committee therefore recommends:

( 1 ) That the Association take no public po-
sition for or against private solo practice, private
group practice, closed panel group practice, fee-
for-service payment, or prepayment by capita-
tion.

(2) That an appropriate committee of the
AMA be charged with the task of establishing
the basic criteria which any proposed system of
delivery of health services or mechanism for
payment must satisfy to be acceptable.

(3) That the Association, in all public state-
ments, emphasize the concept that differences in
education, culture and income levels create prob-
lems that may necessitate different systems of
delivering medical care for different population
groups.

(4) That the state and local medical societies
be encouraged and assisted in devising and pro-
posing practice expedients suited to their local-
ities and their problems.

(5) That the Association, in conjunction with
the state and county medical societies, establish
a consultation and assistance service for physi-
cians or groups of physicians who wish to de-
velop organizations or programs for the render-
ing of health services.

(6) That the AMA endeavor to be informed
of the pilot projects that are proposed by other
sources and that it request the Department of
HEW to discuss those projects with the Associa-
tion before they are put into effect.

(7) That the Association seek to insure that
the value judgments made by the Department of
HEW on plans, programs, pilot projects and pay-
ment mechanisms are firmly based on the cri-
teria and standards the AMA has developed for
that purpose.

APRIL 1970

2 19

HOUSE OF DELEGATES / Continued

MEDICAL SOCIETY NEGOTIATION OF
CONDITIONS, REGULATIONS AND
FEES IN GOVERNMENT PROGRAMS

Another manifestation of the government’s in-
terest in costs has been a careful scrutiny of pro-
fessional fees, particularly those of physicians.
The acceptance by government of the usual, cus-
tomary, prevailing, and reasonable (UCPR)
principle of payment for the Medicare program
was encouraging as an indicator that there would
be no direct attempt to dictate physicians’ fees
beyond keeping reimbursement in line with cur-
rent cost levels. It should be borne in mind, how-
ever, that the adoption of the UCPR concept is
provisional rather than final and that it has yet to
prove itself as an economical method of payment
for health services. Physicians’ fees have been
rising and, in the past few years, they have done
so at a rate exceeding the rise in the various cost
indices. There has also been an appreciable in-
crease in physicians’ incomes since 1966 while,
during the same time, the medical profession has
been unable to bring about a material expansion
of its capacity to deliver health services. In the
face of the unexpectedly high cost of new health
service programs and on the basis of these su-
perficial observations, the right of physicians to
augmented incomes is being questioned in many
quarters.

Aside from using fee levels, which are now
showing signs of levelling off, there are two major
factors that brought about increases in physician
income. The first of these was the abandonment
by government of the charity and “welfare dis-
count” concepts in the provision of health care to
the indigent. Quite correctly, the decision was
made that cut-rate or charitable services did not
result in a high quality of care for the medically
needy, and the principle of payment at the “going
rate” was therefore established. As a result, many
physicians are now being reimbursed for services
they previously rendered gratis, which others are
being paid at a higher rate.

The second factor contributing to the rise in
physician income is the upsurge in demand that
has been created by expanded government fund-
ing of health care for the indigent. Although the
capacity of the medical profession as a whole to
meet this demand may have been insufficient,
many physicians did accept heavier work loads
which increased their incomes correspondingly.

The Committee does not wish to justify the in-
come and fee increments in this report, but it is
important to recognize that rising costs and fees
have already been responsible for one congres-

sional investigation and are causing rumblings
from consumer groups, labor unions, and govern-
ment agencies that fee-for-service and UCPR
merely enrich physicians and encourage the con-
tinuous escalation of charges without correspond-
ing improvements in services. If, therefore, these
methods of payment are to survive, it is impera-
tive that the medical profession be able to dem-
onstrate that fee levels are reasonable and that
they are not permitted to increase without good
cause. In order to do this, the medical societies
at all levels must have access to data that are
unbiased, accurate and beyond challenge.

The Committee heartily supports the UCPR
concept and urges that the AMA and the state
and local medical societies do everything in their
power to widen its application. Nevertheless,
there are many programs which are still based on
negotiated fee schedules such as some state plans
implementing Title 19 and most Workmen’s
Compensation programs. The possibility cannot
be overlooked that the government may turn
from the UCPR concept at some future date in
spite of the efforts of the medical profession. The
societies must therefore be prepared to achieve
usual and customary fees by negotiation as well
as to negotiate the conditions, regulations, and
procedures that apply to physicians participating
in government programs.

There are two essentials to effective negotia-
tion. The first is a complete and accurate body of
information on all aspects of program operation.
The second is a corps of seasoned and know-
ledgeable negotiators.

It is understood that fee negotiations do not
fall within the province of the AMA since most
of these take place at the state or, rarely, at the
county level. On the other hand, the Association
could very well serve a useful function at the
federal level by negotiating all other aspects of
tax-supported health programs. It must, there-
fore, have access to data. In addition, most state
and local societies are hampered in their discus-
sions with government by lack of knowledge of
conditions and developments in other areas.
Many of them do not have effective machinery
for gathering information or have not yet recog-
nized the importance of that function. They
would derive great benefits from analyses and
recommendations made by the AMA, based on
data which the Association in any case requires
for its own purposes.

The Committee therefore recommends that the
Association:

( 1 ) Urge state medical associations to under-
take various studies, including surveys of pre-
vailing medical fees.

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JOURNAL MSM A

1(2) Develop a uniform methodology for con-
ducting such studies to the end that the data from
the various states and localities be comparable.

(3) Serve as a clearing house for the material
thus obtained and, after analysis, redistribute the
data to the state medical associations with sug-
gestions and conclusions.

(4) Urge the state medical associations to des-
ignate negotiators who are qualified to deal
energetically with government agencies on all
matters pertaining to tax-supported programs.
Such individuals or groups should be formally
appointed and the government jurisdiction in-
volved should be notified that all negotiations
will be conducted by them.

COST CONTROL OF HEALTH CARE:
UTILIZATION AND MONITORING
OF PROFESSIONAL FEES

One other aspect of physicians’ fees deserves
consideration. Over the past two or three years,
Association spokesmen have admitted that the
medical profession has a responsibility in help-
ing to keep the costs of health services within
reasonable limits. They accepted for the pro-
fession not only a responsibility for the overall
control of fee levels but also for furthering the
optimum utilization of facilities and ancillary
personnel as a curb on hospital costs. With re-
gard to the latter, the medical associations can
assume only an educational function. The direct
control of hospital utilization must devolve on
appropriate professional groups within the hos-
pitals themselves since such policing is beyond
the scope and authority of medical societies.
This makes utilization control no less a medical
function; it merely places supervision and au-
thority where they can be effectively exerted.

Tn accepting the responsibility for curbing
costs by keeping fees within reasonable limits, our
spokesmen were wise but, under the circum-
stances, over-optimistic. It must be remembered
that medical societies have absolutely no juris-
diction over the charges made by their mem-
bers. Medical society grievance committees, in
adjudicating fee disputes between physicians and
third parties, act on the premise that they are
merely limiting the financial obligation of the in-
suror, rather than setting a value on a physician’s
service or a ceiling on his charges. When hear-
ing disputes on fees between individuals and
their physicians, such committees either rely on
the exercise of moral suasion or they require pre-
liminary agreement by both parties to accept the
outcome of arbitration. In no case do grievance
committees or the societies they represent have
the legal power to require a physician to reduce

his charges. As far as tax-supported programs are
concerned, there are other means that can be
used to control fees, such as the withholding of
payment for services by the paying agency either
on its own decision or on the recommendation of
the medical society concerned. In some instances,
physicians have been excluded from programs
they were allegedly abusing or have been re-
quired to seek authorization prior to treatment.
Again, this is done on the authority of the pro-
gram administrator, with or without the advice
and consent of the medical society of the area.

The medical profession must now decide
whether it is prepared to meet the obligation it
has accepted for cost control through the mon-
itoring and containment of fee levels. If the an-
swer to that question is in the affirmative, a
choice must be made between relying on the
powers of program administrators for enforce-
ment and seeking direct authority for the medi-
cal societies at state and county levels.

The Committee is of the opinion that fee po-
licing or, indeed, any other supervision of phy-
sicians is best kept in the medical societies. Peer
judgments are much more likely to be just and
equitable in these matters than are decisions
made by outside agencies. At the same time, if
the societies elect to make only the judgments
and, by agreement, leave enforcement to gov-
ernment agencies, they may at some future time
be excluded from both functions.

Again, the monitoring of fees does not fall
within the province of the AMA but the Asso-
ciation should advise the state and county medi-
cal societies to assume that function and should
assist them in securing the necessary powers.

The Committee therefore recommends:

( 1 ) That the AMA urge state and county
medical societies to assume the functions of
monitoring fees and containing the costs of health
care.

(2) That the Association, in cooperation with
the constituent societies, determine what powers
the state and local societies require to serve these
functions and how those powers can be best ob-
tained.

AUDIT AND POSTGRADUATE STUDY

The medical profession has accepted other ob-
ligations in the operation of tax-supported pro-
grams, particularly Titles 18 and 19 of PL 89-97.
Written into this law are requirements for med-
ical audit to assure the government that it is pay-
ing for services of acceptable quality. In-hospital
audits are being conducted by the hospital pro-
fessional staff and are apparently encountering
no major difficulties since there are no problems

APRIL 1970

221

HOUSE OF DELEGATES / Continued

of authority involved. However, it should be
noted that the science or art of evaluating medi-
cal services on a large scale is in its infancy, to
say the least. The peer judgment method, when
limited to a few randomly selected cases, is
crude, time-consuming and relatively uninforma-
tive. The conclusions drawn from a few well
publicized studies of this type in the early 1960’s
demonstrate their inaccuracy and the facility with
which improper selection can distort the findings.

If in-hospital audit of medical services by the
peer judgment method is to be effective and if
it is not to require a prohibitive expenditure of
physicians’ time, mechanical or electronic means
of pre-selection must be developed so that audi-
tors are given high-yield batches of cases to re-
view. Both the pre-selection methods and the
audit criteria must be uniform through several
counties, a region, or even a state, so that mean-
ingful comparisons can be made. It would even
be advantageous to develop them on a nation-
wide basis.

If in-hospital audit of medical services is in
its infancy, the audit of office services is barely
embryonic. Nevertheless, partly as an outgrowth
of the distorted studies previously alluded to, the
public has developed a lack of confidence in the
quality of medical care. In-hospital audits may
ultimately allay their fears concerning the care
they receive in these institutions but, since office
services, unlike hospital services, are completely
unsupervised, demands are being made in some
localities for evaluation of the quality of office
practice.

In New York City, for instance, the adminis-
trators of the Medicaid Program are conducting
on-site surveys of some physicians, particularly
those who bill in excess of certain amounts for
services rendered to assistance recipients. The
basis of this particular selection is that the vol-
ume of services rendered precludes, or may pre-
clude, their being of high quality. There is al-
ready clear evidence, however, that the adminis-
trators intend to extend this procedure to the
maximum degree possible. Although the medical
societies have protested this activity on grounds
that will be developed in this report, it is con-
tinuing and is being enforced by the city’s power
to withhold payment or to disqualify individual
physicians from Medicaid practice. The situation
in New York is as yet unique but it does serve as
an example of what may happen in government
programs.

On the same subject of office audit, the Com-
mittee reviewed with great interest the report en-

titled “Continuing Medical Education — A New
Emphasis,” emanating from the Association’s Di-
vision of Medical Education. The Committee does
not wish to review that report which, incidentally,
is well worth reading, but a few of the findings
are germaine to this discussion.

The educational process described in the re-
port is ingenious and stimulating but of even
greater interest is the motivation of the physi-
cians who participated and the implications that
motivation has for the quality of care.

Essentially, the physicians of Utah were given
a mechanism whereby they could evaluate their
skills and self-analyze their educational deficien-
cies. On the basis of their analyses, they were
given an opportunity and a time-economical
method to update their skills in a priority se-
quence.

What is of the utmost significance is the fact
that on the initial contact 476 physicians respond-
ed out of a possible 907 for a response rate of
over 50 per cent. Many of the non-respondents
were specialists who already had facilities avail-
able for the continuation of their medical educa-
tion. Surely this pilot project indicates that much
of the problem of continuing medical education
can be solved on a voluntary basis if the proper
programs are developed.

The great advantage of the voluntary ap-
proach is that the individual physician is likely
to spend his study time in the fields that have
the greatest importance to his own practice and
in which he may need additional education most
urgently.

If we compare this to the external-audit-by-
officialdom approach, it becomes obvious that the
latter is punitive and regulatory in nature. Un-
der these circumstances, the best that can be ex-
pected of physicians is minimum compliance and
thus, in a very real sense of the word, the external
audit is self-defeating. It is therefore in the in-
terest of physicians and patients alike that ef-
forts to perfect and widen the application of
voluntary self-audit and postgraduate study be
accelerated and that, to the extent possible, gov-
ernment health officials be convinced that the ob-
jectives they hope to attain by instituting their
own audits are better achieved by voluntary
means.

In spite of these arguments, it seems necessary
to assume that the demand for the evaluation of
the quality of office medical and surgical proce-
dures will increase, especially as government pro-
grams and insurance plans cover more of these
services. Even management and those unions
that purchase health insurance for their members
are beginning to demand proof of the quality of

222

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the care for which they are paying with their
premiums.

In their present state of under-development,
however, externally conducted office audits can
do little but hamper physicians in their work and
yield data that are impression or surmise at best.
Methods of evaluation must therefore be de-
veloped that are sparing of physicians’ time and
that produce factual and useful conclusions. It is
also important that the legality of such audits with
regard to the privacy of the patients’ records
be determined.

The Committee therefore recommends that
the AMA:

( 1 ) Endorse the principle of voluntary, life-
long postgraduate study for all physicians and
continue and accelerate the development of pro-
grams and incentives for such study.

(2) Through the state medical societies, in-
vestigate the current status of in-hospital audit
methods and make a similar investigation of the
state of development of the evaluation of office
services.

(3) Encourage and assist the state medical
societies and state departments of health and
welfare to develop uniform and effective meth-
ods of audit for both office and in-hospital ser-
vices, based on electronic data processing, to the
maximum possible extent.

(4) Request the Law Division to clarify the
extent to which a physician's responsibility for
the privacy of his patients’ records will permit
him to cooperate in an audit of his office prac-
tice.

SPECIAL REQUIREMENTS TO PARTICIPATE
IN GOVERNMENT PROGRAMS— LICENSURE

If we assume for a moment that excellent
evaluation methods have been developed, what,
then, do we do with physicians who are practic-
ing demonstrably poor medicine? To revert to
New York City, such cases, with their documen-
tation, are being referred to the county medical
societies for action. Those societies, however,
have no jurisdiction over the quality of medicine
practiced by their members, their qualifications,
or their efforts to keep their skills current. They
can admonish but not act.

This lack of specific authority has led the
New York State Department of Health to ex-
trapolate its legal responsibility for the quality
and availability of health services into a right to
demand qualifications of specialists and postgrad-
uate study requirements of generalists who wish
to render services to Medicaid patients. The re-
quirements themselves are not unreasonable but
they raise the difficult and important question

of whether a physician requires a second license,
other than that granted by the usual state licens-
ing agency, to render services to patients under
tax-supported programs.

The mere existence of a double standard is
undesirable and it seems logical that, if the quali-
ty of practice in a state is poor among an ap-
preciable number of physicians, the state’s re-
quirements for licensure and practice are inade-
quate and should be tightened. Once the deter-
mination has been made that this is the case, the
drafting of new standards would best be accom-
plished by the cooperative efforts of the Board
of Regents, the State Department of Health, and
the State Medical Association.

The true extent of this problem of quality, if
it is a problem, has never been assessed. Cer-
tainly it is not very great with the specialists. Al-
though their associations impose no postgraduate
study requirements on them, their certification re-
quires a certain level of initial training and the
regulations of the hospitals in which they must
practice insure at least a degree of exposure to
the advances in their field.

The generalist, on the other hand, can be li-
censed in most states with little graduate training
and if he is not a member of a general practice
academy or a hospital staff member he may nev-
er attend another conference, seminar, or lecture
in his life. Again, the Committee has no con-
crete evidence that this happens to any great de-
gree and the general practice academies, as they
expand their memberships, are making rapid
strides toward making postgraduate study for
generalists, on a voluntary basis, more universal.

In spite of the fact that deficiencies in the
quality of medical care have not been demon-
strated or documented, various recommendations
have been made for both specialists and general-
ists to insure that they are maintaining their
skills. These include compulsory postgraduate
study, periodic reexamination, recertification and
relicensure.

To a degree, most of these proposals are over-
reactive and although the Committee does not
oppose their general intent, their heedless appli-
cation may have grave consequences. The ques-
tions must be asked whether these expedients
would be effective; how much hardship they
would create for the hardest working and most
needed segments of the profession; what general
and regional shortages of medical manpower they
would cause; and if they are necessary, by whom
should they be promulgated and enforced?

The Committee finds it difficult to advocate or
support compulsory requirements until the volun-
tary alternatives have failed. Yet it is aware that

APRIL 1970

223

HOUSE OF DELEGATES / Continued

public and governmental pressures are already
being exerted for compulsory requirements, at
least as far as tax-supported programs are con-
cerned. State medical societies have generally
taken little action in this regard. The Oregon
Medical Association has adopted an interesting
and perhaps unique “shape up or ship out” pol-
icy on postgraduate study that may well be ef-
fective there but that would be subjected to al-
most immediate legal challenge in many other
states.

In general, rather than accept a double stan-
dard for licensure, it would seem preferable to
revise the state education laws or, better yet, to
develop a national professional education law
that would modernize and update undergraduate,
graduate and postgraduate requirements.

The Committee therefore recommends:

( 1 ) That the AMA encourage and assist all
state medical associations to devise programs for
voluntary postgraduate study designed to main-
tain medical education at an optimum level and
to be least disruptive to the provision of medical
services.

(2) That the Association obtain information
from each state medical society as to whether
special requirements have been imposed on phy-
sicians who render services to patients under the
provisions of tax-supported programs and obtain
the specifics of what those requirements are.

(3) That in those states where the health or
welfare departments have imposed special re-
quirements on physicians to participate in their
programs, the medical society reject those re-
quirements and that, if the need for such regula-
tion can be demonstrated, the state medical so-
ciety, education department, and health depart-
ment cooperatively develop standards to be in-
corporated into the education law and enforced
on ail physicians of that state, thereby eliminat-
ing double standards for medical practice and
restoring the licensing authority to the proper
agency.

HOSPITAL BED SHORTAGES; UTILIZATION;

PHYSICIAN-HOSPITAL RELATIONSHIPS

Before the enactment of PL 89-97, one third
or more of this country’s entire bed capacity was
obsolescent. The chronically underfinanced vol-
untary hospitals were forced to postpone capital
improvements and construction to meet steadily
rising operational costs. Rapid advances in medi-
cal technology brought the obsolescence rate to
a point where the entire national hospital plant

was in a state of gradual but steady deterioration
and shortages of hospital beds became progres-
sively more acute and more widespread.

Although the implementation of Medicare and
Medicaid did not increase hospital utilization as
much as had been feared, it did augment the de-
mand considerably. This, coupled with grave de-
ficiencies in extended care facilities and a con-
sequent misuse of hospital beds, has further ag-
gravated hospital bed shortages. It is question-
able that construction of hospitals and extended
care facilities will catch up with these deficiencies
in the next five or ten years.

To minimize the effect of the short supply of
beds, the Medicare Law requires utilization re-
view procedures in all approved hospitals. The
problems inherent in utilization review are not as
great as those in medical audit, but the same
general comments apply. The methods adopted
by the hospitals lack uniformity and the data
adduced in the hospitals, cities, regions, and
states are not comparable. The shortages of beds
in all categories, however, is an enormous in-
centive to physicians and hospitals alike to
achieve optimum utilization. Until those short-
ages are eased, the misuse of hospital facilities is
not likely to be tolerated.

There are some aspects of hospital utilization,
nevertheless, which still merit study. As extend-
ed care beds and home care personnel become
more available, the choice of the correct facility
will become an important factor in proper utili-
zation, and guidelines should be developed to as-
sist physicians in making their choice. The use of
x-ray departments and laboratories on a more or
less continuous basis should be explored with the
object of cutting down preoperative waiting time
and eliminating the week end hiatus syndrome.
The improved use of OPD facilities both for pre-
operative work-up and to avoid admissions is
another example that comes to mind.

A thorough discussion of utilization is beyond
the scope of this report but the Committee notes
that physicians, as individuals, have a major
responsibility and role in achieving the best pos-
sible utilization of hospital facilities, a responsi-
bility they are rapidly learning to meet. Many
medical societies have studied utilization prob-
lems in some detail and are ready to assist and
cooperate with hospitals if they find the welcome
mat out. The achievement of goals in utilization
will require the efforts of all three groups and the
establishment of the necessary relationships is
the responsibility of all three.

The lack of an adequate number of hospital
beds has also had a profound effect on the re-
lationships between physicians and their hospitals

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as well as the relationships between salaried and
voluntary staff members. As teaching programs
are expanded, the salaried staff grows in size and
influence while more and more beds are pre-
empted for teaching purposes. Accommodations
available for patients of voluntary staff physi-
cians have dwindled progressively and the wait-
ing period for admission of such patients is now
six weeks or more in some cities. Since the avail-
ability of hospital beds is a matter of survival for
private practitioners, this situation has given rise
to much rancor.

Admittedly, there are pressing problems on the
academic side as well and it would seem that
both groups have a great stake in reconciling
their differences. Actually, in most hospitals ma-
jor disagreements still exist. The recommenda-
tion has often been made that all patients be part
of the teaching program and that hospitals and
physicians work together to eliminate the legal
and social barriers that may exist. Yet the teach-
ers wish to retain control of their services and
the private attendings their authority over the
care of their patients and, except in a very few
hospitals, no solutions have been forthcoming.

In addition to these sources of friction, the dis-
tribution of funds earned for services rendered to
patients for whom there is government reim-
bursement available has created ethical, legal,
financial, and organizational problems. These
questions have too many implications and rami-
fications to be considered thoroughly in this re-
port. The Committee merely wishes to note that
the House of Delegates, in adopting Resolution
40 in November 1967, recognized the existence
of these trouble spots in hospital staff relations
and laid down guidelines intended to eliminate
those having to do with the distribution of in-
come. The guidelines are insufficient to solve
even this one facet of the total problem but they
are a beginning and can be further broadened
and refined.

The “town and gown” stress syndrome war-
rants much more than mere academic interest.
Its importance grows as hospitals expand, merge,
and reorganize and as hospital care patterns are
modified and staffs are reconstructed. The medi-
cal associations have no direct authority over
hospitals and, generally speaking, the attending
physicians at each institution must work out then-
own formula for their relationships with each
other and with their hospital. The hospital asso-
ciations are similarly limited in their authority
over member hospitals. Nevertheless, in some
areas the medical societies and the correspond-
ing hospital associations have been able to agree
on some basic principles that apply to these staff

situations and are gradually prevailing on hos-
pital administrations to accept them. This is a
slow and roundabout process but it seems to be
the only way to regularize these complex rela-
tionships and restore peace and stability to hos-
pital staff functions.

The Committee therefore recommends :

( 1 ) That the Association secure data from
state and county medical societies on problems
in physician-hospital relationships in their areas
and the measures, if any, that are being taken to
solve them.

(2) That, on the basis of these data, the As-
sociation identify the basic principles that apply
to staff-hospital relationships and encourage state
and county medical societies to do the same.

(3) That the Association and each state and
county medical society request its counterpart in
the hospital association structure to assist in de-
veloping guidelines and urge their member asso-
ciations and hospitals to implement them.

EFFECTS OF MEDICARE AND MEDICAID
ON VOLUNTARY HEALTH INSURANCE

No discussion of PL 89-97 and its impact on
medical practice would be complete without an
analysis of its effect on voluntary health insur-
ance and the voluntary carriers. One aspect of
this relates to the manner in which the carriers
are functioning as intermediaries in Part B of Title
18.

Following the enactment of PL 89-97, the
medical profession, through the Association,
strongly supported the use of the Blue Shield
Plans in the administration of the medical por-
tion of Title 18 and, where possible, that of
Title 19 as well. Although the Blues were not
designated the sole administrators of Title 18,
they did succeed in being selected as intermedi-
aries in the majority of cases.

It is interesting and informative to speculate
on precisely why physicians were so anxious to
have the Blue Plans administer the Title 18 and
Title 19 programs. One reason was that the Blue
Shield Plans were existing, functioning entities
with a known capacity for program administra-
tion. Another was that their requirements, forms
and procedures were familiar to the physicians
who had supported their programs through the
years. Most physicians believed that the employ-
ment of the Blue Plans in an administrative ca-
pacity would lessen the confusion and delays that
might be experienced in the transition period
during which beneficiaries were being transferred
from their old coverage or being enrolled anew.
By this time, the profession had expressed a
strong preference for payment on the basis of

APRIL 1970

225

HOUSE OF DELEGATES / Continued

UCPR fees. The National Association of Blue
Shield Plans was already advocating payment on
this basis for its national accounts and urging the
individual plans to put it into effect in their other
underwriting. This conformity of views also had
its effect in persuading physicians to support
utilization of the Blue Shield Plans wherever pos-
sible in the operation of federal health programs.

The final, and perhaps most significant factor
in the adoption of this policy by the profession,
was the belief that the Blue Plans were receptive
to the thinking and wishes of physicians since,
after all, the medical profession had majority
representation on the boards of directors of most
plans. Physicians have always had an almost ata-
vistic distrust and fear of government intrusion
into any aspect of medical practice. Perhaps sub-
consciously they hoped that the Blue Shield Plans
would be an effective buffer between them and
government.

These hopes of the medical profession were
unrealistic to some extent and, as a result, they
were not fulfilled. Since the Blue Shield Plans are
employed an intermediaries, rather than carriers,
they administer but have no fundamental role in
policy making. While the Blue Plans and other
intermediaries do have elaborate committee
structures to advise the government, in the final
analysis all policy decisions are made by the So-
cial Security Administration and the Department
of Health, Education, and Welfare. The influence
that the medical societies hoped to exercise over
the Title 18 and Title 19 programs, through their
close association with the Blue Shield Plans, has
therefore proved to be illusory.

Program administration by intermediaries is
itself subject to certain inherent disadvantages.
On a national scale it is cumbersome, since the
Social Security Administration must relate and
adapt to a large number of carriers which vary
greatly in their methods, capacities, and sophisti-
cation of equipment. In addition, the SSA, after
raising Part B premiums by 33 V3 per cent on one
occasion, recently averted another increase only
by making several administrative adjustments. Al-
though the SSA has publicly announced its satis-
faction with the performance of the intermedi-
aries, many in government, for these and other
reasons, consider this type of operation to be in-
effective.

The health insurance companies are dissatis-
fied with the difficulties and restrictions that the
intermediary variety of administration has im-
posed on them and they have been pressing for a

true carrier relationship with the program. They
believe that this would simplify their operations
and normalize their relationships with paying
agencies, subscribers, and physicians. The De-
partment of Health, Education, and Welfare has
so far resisted making this change and there is
mounting speculation that, at some time in the
not too distant future, the intermediaries may be
eliminated and the entire operation shifted to
Baltimore.

The Committee feels that the elimination of
the voluntary and commercial carriers would be
unfortunate and recommends that the Associa-
tion exert what influence it can for their reten-
tion. Nevertheless, it must be borne in mind that
in their present role they have limited decision-
making capacity and cannot negotiate directly
with providers of services or their organizations.
Present attempts by medical societies to modify
the Title 18 program are therefore indirect, un-
wieldly, and generally unsatisfactory. In addition,
if government should decide to take over the op-
eration of the Title 18 program entirely, the As-
sociation would find itself without any established
channel of communication with the administra-
tors of Medicare and possibly other future federal
programs. It has become clear that what Medicine
hoped to use as a buffer between itself and gov-
ernment has become an insulator. The Commit-
tee is of the opinion that such insulation is un-
desirable and that all medical societies should
seek to establish and maintain open, direct chan-
nels of communications with the agencies that set
policy for government health programs.

Public Law 89-97 is also having a major effect
on voluntary health insurance programs, which is
of interest and significance to the Association.
Although the concept of limiting health insurance
to catastrophic coverage has disappeared almost
entirely from voluntary health insurance, Blue
Shield programs still have substantial limitations
of benefits and often fall far short of providing
full reimbursement for medical care costs.
Through Medicare, the elderly now enjoy, or can
enjoy, a wider spectrum of benefits and a higher
level of reimbursement than are normally avail-
able through voluntary programs. Medicaid, in
spite of exclusions, restrictions placed on federal
contributions, and frequently substandard reim-
bursement for suppliers, still requires that the
indigent ultimately be given a complete range of
supplies and services at no cost to them.

Since public and private programs exist side
by side, comparisons are inevitable. They have
not been flattering to the plans offered by volun-
tary carriers and have led to demands by both

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JOURNAL MSM A

labor and management that the plans greatly in-
crease their benefits. Unfortunately, the voluntary

I segment of the health insurance industry is being
called on to match the generosity of the federal,
state, and local governments at the very time that
health care costs are rising most steeply and pub-
lic resistance to premium increases is at a maxi-
mum. Caught between these two pressures, the
Blue Plans will continue to run behind public ex-
pectation, which will augment the clamor for
more government supported programs. If the
populace is not offered voluntary coverage that
is reasonably comprehensive at premium rates
that are not excessive, they will turn to govern-
ment administered, tax financed programs. Even
if their benefits are provided predominantly
through prepayment programs which limit their
choice and prohibit a person-to-person relation-
ship with their physicians, they will sacrifice these
features to minimize or eliminate out-of-pocket
payment. This is a challenge the voluntary health
insurors must meet and they are hampered in
their efforts by behavior patterns they have es-
tablished. In the past. Blue Shield Plans have
been generally unimaginative in devising new
benefits and have extended their coverage into
new areas of health service only under consumer
pressure. Policies have too often been tailored to
the premiums that could be charged without re-
gard to whether they met basic minimum re-
quirements. Such marketing practices are no
longer appropriate in dealing with sophisticated,
well-informed and critical consumer groups, but
they are being abandoned slowly and reluctant-
ly-

The National Association of Blue Shield Plans
(NABSP) apparently recognized the threat posed
by these deficiencies. In October 1968, at a spe-
cial meeting, its membership standards were
made more stringent by requiring its member
plans to make paid-in-full programs, based on
usual, customary, and prevailing rates, available
to their subscribers. This is an encouraging step
toward the goal of more complete reimbursement
of subscribers for their health care expenditures.
It should logically be followed by efforts to move
the individual plans toward upgrading their bene-
fits in terms of the range of services they cover.
The Association, through its recently formed li-
aison committee with the NABSP, should en-
courage and stimulate further progress along
these lines.

The reason for the creation of the Associa-
tion’s liaison committee with the NABSP calls
for one more comment. For a variety of reasons,
some Blue Shield Plans have been showing a
tendency to deal directly with the physicians in

their area and to circumvent the medical societies
that represent those physicians. This tendency
found expression in the policy which was adopt-
ed at the 1967 annual meeting of the NABSP
and which led to the formation of the liaison
committee. The Committee is of the opinion that,
at this time, when the entire system of providing
and paying for health services is under critical
public appraisal, the relationships between the
medical profession and the Blue Shield and Blue
Cross Plans should be close, cordial, and coop-
erative. In most Blue Shield Plans, the medical
profession has majority representation on the
board of directors. These board members are di-
rect links between the plans and the societies
that corresponds to them. The medical societies
would do well to reexamine their representatives
at this time to insure the effective exercise of
their policies and their influence.

As far as Blue Cross is concerned, the in-
fluence of the medical profession is considerably
less pronounced. Nevertheless, an effective
strengthening of ties between the medical societies
and their corresponding Blue Cross Plans is de-
sirable at all levels. The Committee knows of no
liaison groups with the Blue Cross national or-
ganization that would correspond to that with the
NABSP. Since many of the Association’s con-
cerns and interests in health care are directly re-
lated to the financing of hospital services, the
establishment of such a committee would seem to
be indicated.

To summarize this topic, the Blue Shield Plans
are changing in their fundamental nature in re-
sponse to pressures from government, from con-
sumers and from the Blue Cross Plans with which
they are associated. Their dependence on the
medical profession has diminished, and they are
generally less responsive to the opinions and the
guidance of the medical societies. The loosening
of ties is further aggravated by the long tenure of
most of the medical members of the boards of di-
rectors who, having outgrown their society ties, no
longer reflect current medical policy and often fail
to alert their medical societies to changes in Blue
Shield operations and their significance. The
stresses to which our health care system is cur-
rently being subjected call for new and imagina-
tive approaches to the utilization and distribu-
tion of our total pool of resources in terms of
manpower, facilities and money, if voluntary sys-
tems are to survive. Blue Cross, Blue Shield,
and the Association all have a vital interest in
voluntarism in health care. That joint interest
calls for them to close ranks and coordinate their
efforts and their planning.

APRIL 1970

227

HOUSE OF DELEGATES / Continued

The Committee therefore recommends:

( 1 ) That the Association, through its current
liaison with the NABSP, seek the obtain con-
tinuous and current information on the Medicare
Program; that it secure data on the development
of additional benefits, new fields of coverage, and
minimum standards of benefits in voluntary
plans; and that, through the NABSP, it stimulate
the Blue Shield Plans to greater efforts in up-
grading their programs.

(2) That a similar liaison committee be de-
veloped in conjunction with the Blue Cross Na-
tional Association for similar purposes.

(3) That the AMA advise state and county
medical societies to take similar action at their
respective levels and to review their representa-
tion on the boards of directors of their local
Blue Plans to be sure that their representatives
are individuals who are currently active in society
affairs and familiar with society policy.

(4) That the Association seek a formal and
direct channel of communication with the De-
partment of Health, Education, and Welfare,
with the object of developing its own capacity
for modifying existing and new programs when
such modification is indicated, rather than relying
solely on the NABSP for this purpose.

PRIORITIES OF HEALTH SERVICES

In earlier portions of this report, reference was
made to an increasing demand for “comprehen-
sive” or “patient-oriented” health care. The pa-
rameters of such care have been described only
in generalities and nowhere has the Committee
been able to find an authoritative definition of the
word “comprehensive” as it applies to health ser-
vices. Since the principle of comprehensive care
has been generally accepted, it is important to
determine precisely what services represent mini-
mum acceptable and optimum levels. If the re-
sources are available to supply all services repre-
senting optimum care simultaneously and imme-
diately, there is no major problem. If, on the
other hand, those resources are not on hand, it
becomes necessary to evaluate all services in
terms of their importance, urgency, and cost ef-
fectiveness, and to establish minimum standards
and priorities on that basis.

The following is a partial, cumulative list of
services advanced as essential elements of op-
timum health care, culled from a number of
sources:

( 1 ) Necessary care for all acute illnesses, so-
matic or mental, of high quality, immediate avail-

ability, and rendered in a suitably equipped fa-
cility.

(2) The same care for chronic illness without
limitation of time or cost.

(3) A program for the continuous monitoring
of health, growth, and development from birth
to adult life.

(4) Periodic, regular health inventory of
adults to prevent disease or detect it in its early
stages.

(5) Periodic and regular evaluation of men-
tal health.

(6) A formal program of health counselling
to function in conjunction with 3, 4, and 5 above.

(7) Disease and accident prevention pro-
grams.

(8) Occupational counselling based on ap-
praisals of the individual’s background, attitudes,
aptitudes, and aspirations.

(9) Social service counselling for domestic, be-
havioral and environmental problems.

(10) A healthful environment in terms of
housing, control of air and water pollution, sani-
tation, noise abatement, transportation, education
and civil rights.

(11) Central maintenance of complete and
readily retrievable data on each individual.

HEALTH BILL OF RIGHTS

It seems almost self-evident that a program for
more or less complete health services as described
above is not immediately possible, even for se-
lected population groups. The Committee there-
fore recognizes a need for the identification of
both short-term and long-term goals in health
care for all individuals, possibly in the form of a
“Health Bill of Rights.” Such a statement, cou-
pled with accurate data on existing human and
material resources, would be of inestimable value
in planning public programs that are realizable,
effective and make most advantageous use of
money, facilities and manpower. The statement
would also serve as a yardstick to measure the
adequacy and the progress of voluntary health
insurance programs.

The Committee therefore recommends that:

( 1 ) An appropriate committee or division of
the Association gather information from the state
medical societies on the availability of physi-
cians, ancillary personnel, hospital beds in all
categories, laboratories, public health nurses, so-
cial service workers, and all other types of health
professionals.

(2) The Association promulgate a “Health
Bill of Rights” to identify the services that com-
prise comprehensive health care.

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JOURNAL MSM A

(3) On the basis of the data obtained from
the state medical societies, the Association es-
tablish minimum standards for health care and a
system of priorities for the provision of services
beyond those minima, thus creating both an imme-
diate and a long range schedule for their attainment.

(4) The Bill of Rights, the data and the stan-
dards and priorities receive wide publicity.

HEART DISEASE, CANCER, AND
STROKE— PL 89-239

Public Law 89-239, known as the Heart Dis-
ease, Cancer, and Stroke legislation, established
and funded regional medical programs. On a na-
tionwide basis, these programs are off to a patchy
start. In some sections of the country, medical
educators are actively perfecting methods of rap-
idly disseminating the information derived from
research with the object of reducing the time be-
tween the discovery or development of new prin-
ciples, theories and techniques and their clinical
application. Even this early in their development,
these local programs promise to become the most
important single vehicle for the coordinated in-
struction of practicing physicians through radio,
television, and mail or direct testing and educa-
tion sessions. Many such programs have created
channels of intercommunication to supplement or
enhance the scientific content of their material
and improve their didactic methods.

In other areas, progress has been disappoint-
ingly slow. This has in part been due to the fact
that some medical school deans, exercising a dis-
proportionate degree of control over the Regional
Medical Programs, have been reluctant to allow
projects in postgraduate education to dilute the
purity of their graduate teaching and research ef-
forts.

In spite of the unevenness of its growth and
development, the program as a whole has great
potential and it merits the continued interest and
support of the Association and the constituent
and component medical societies.

PARTNERSHIP FOR HEALTH— PL 89-749

One more item of recent health legislation de-
serves comment here since it may eventually
have a profound influence on medical practice.
Public Law 89-749 provides federal matching
funds for the development and operation of
Health Planning Commissions under which the
state and regional agencies for comprehensive
areawide health planning will function. In some
areas, where good relationships prevail among
local government, the health professions, volun-
tary health agencies, community groups, and the
regional hospital planning council, their organiza-

APRIL 1970

tion is proceeding briskly. In other regions, plan-
ning agencies are not being formed because of
bickering among these groups, each anxious to
secure the planning function as its own exclusive
property.

In many localities, officials of the various de-
partments involved in the provision of health
services are not accustomed to dealing with pro-
fessional societies, the voluntary health agencies,
and community groups. Some see community-
based planning agencies as a threat to their own
authority and their empires. The local govern-
ment, in these instances, attempts to gain con-
trol of the planning council and exercises its veto
power over other proposals for agencies with
wide community representation.

It appears to be the intent of the law that con-
sumers, or the public, play a substantial role in
planning for their own health care. The law spe-
cifies, in rather loose terminology, that either the
directors of the planning agency or its advisory
council must have at least 51 per cent consumer
representation. Many consumer and community
groups do not yet have individuals to represent
them who are experienced, well informed, and
have the vision to look beyond immediate factional
interests. Such representation takes time to de-
velop and its lack will delay the achievement of
effective planning. Nevertheless, the intent of the
law is clear and these groups should be incor-
porated into the planning commissions and en-
couraged and assisted in every way.

It is hardly necessary to add that the volun-
tary health agencies and the professional societies
can contribute much specialized knowledge and
expertise in planning for health. They should be
amply represented on the executive bodies of the
regional health planning councils.

As presently projected, the planning councils
will have no direct authority. They will merely
study, plan, and advise. Since they will be plan-
ning for health in the broadest possible sense,
they will be faced with an awesome array of
problems. The programs and plans they develop
to solve these will depend for implementation on
the administrations, government agencies, and of-
ficials of several jurisdictions, who may or may
not cooperate with the planning body or each
other. It appears likely that the early stages of
the comprehensive areawide health planning
councils will show some degree of confusion, dis-
organization and ineffectiveness, both in plan-
ning and execution. Nevertheless, as the popula-
tion density increases, coherent environmental
planning is becoming an absolute necessity and
some means will have to be found to minimize
dissension and either encourage or require the

229

HOUSE OF DELEGATES / Continued

various legitimately interested groups to cooper-
ate with one another in the general interest.
The only body with the requisite authority to do
this under the provisions of PL 89-749 is the
state health planning commission. Many such com-
missions have refrained from exercising that au-
thority to the detriment of their programs.

To date, PL 89-749 has had little effect on the
public or the health professions since the pro-
grams are not well advanced. The Committee is
of the opinion, however, that this law will have
the most far-reaching consequences as the plan-
ning councils mature and reach their full power.
Planning agencies are generally ineffective un-
less they have the authority to impose their pro-
grams on those who must put them into effect.
That was the experience with many regional hos-
pital planning councils which, originally limited
to advising officials and departments of govern-
ment, were given direct control over hospital
modernization and construction. The areawide
comprehensive health planning councils will prob-
ably go through the same evolutionary process.
If they do, in all likelihood they will absorb the
regional hospital planning councils and the re-
gional medical programs. Public Law 89-749
would then become the umbrella law under
which all health services would be planned, pro-
grammed and coordinated. The implications of
this law to the health professions is clear.

The concepts underlying areawide compre-
hensive health planning are too well known and
accepted to require discussion in this report. The
Committee does, however, wish to direct the As-
sociation’s attention to the manner in which the
medical profession, through the medical societies
and the AMA, should relate to the planning coun-
cils and the planning effort. There are several
points to be made:

( 1 ) The medical societies at all levels should
support the concept of PL 89-749 and aid in
every way possible to establish properly consti-
tuted planning agencies.

(2) The medical societies should actively sup-
port and promote the establishment of areawide
comprehensive health planning agencies, at lo-
cal levels, that have broad community represen-
tation on their boards of directors, in contradis-
tinction to their advisory committees or councils.
It is inadvisable to permit local governments,
composed as they are of elected and appointed
officials of varying capability and tenure, to dom-
inate or control health planning.

(3) State and county medical societies should
seek or, if necessary, demand their proper rep-

resentation on the executive bodies of the plan-
ning councils. The societies should not accept a
purely advisory function,

(4) To this end, the state medical societies
should make every effort to inform physicians
and county medical societies of the details of PL
89-749, the role they should seek in areawide
planning, and their legal recourse if they are not
accorded proper representation.

The Committee therefore recommends:

( 1 ) That the Association request the state
medical societies to submit information on the
status of comprehensive areawide planning in
their states and the problems that are being en-
countered.

(2) That this information be analyzed, sum-
marized, and redistributed to the state societies,
together with the suggestions made in the pre-
ceding paragraphs and a resume, prepared by the
Law Division, of the provisions in the law that are
pertinent to those suggestions.

(3) That the implementation of comprehen-
sive areawide health planning be reviewed peri-
odically and that the state and county medical
societies be advised of the problems and pitfalls
in this difficult but important area of endeavor.

PART II

THE NATURE OF THE AMA LONG
TERM RECOMMENDATIONS

An analysis of the structure of the AMA and
an evaluation of how suitable that structure is to
effect the most rapid and complete attainment of
the Association’s objectives can best be made in
the light of a projection of future conditions. Rec-
ommendations regarding organization or reorga-
nization must be based on the accurate identifica-
tion and assessment of the trends, forces, and
agencies with which the Association will have to
deal effectively if it is to achieve its goals.

SUMMARY OF PROBABLE FUTURE
ENVIRONMENT

The prediction of future conditions requires a
summary and partial repetition of a number of
observations, opinions, and value judgments that
have already appeared in this report.

It seems safe to predict that the cost of health
services, both per unit and overall, will continue
to rise, although not as spectacularly as they have
in the past few years. The need and effective de-
mand for services will also multiply and, although
the capacity of the health establishment to pro-
vide services will expand considerably, it will con-
tinue to run behind public expectations and re-
quirements. The interaction of increasing costs,
growing demand, and scarcity of services will in-

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JOURNAL MSM A

evitably result in greater government expendi-
tures for health care programs, as well as for
capital construction and modernization of facil-
ities. As these sums constitute a progressively
larger portion of the budget, they will insure con-
tinuing legislative and administrative scrutiny of
costs, delivery systems, and the distribution of
facilities and personnel. In the private sector these
same trends, plus mounting consumer pressure for
a more complete spectrum of coverage, will ne-
cessitate substantial premium increases; and will
also be an invitation to government investigation,
intervention, and control. These problem areas
are not amenable to immediate or complete so-
lution, and since they have awakened individual
and group consumer interest, they will create
growing pressure for government financing and
for public control of health services, facilities,
and planning. Much attention will be paid to the
mechanics of delivering health services, the man-
ner in which health professionals are paid, and
the levels of their reimbursement.

It is a matter of record that the Department of
Health, Education, and Welfare is strongly in fa-
vor of some type of compulsory federal program
for financing health services. Although the chief
exponent of that policy is no longer Secretary of
the Department, it would be naive to expect a
complete turnabout in philosophy, or to under-
estimate the forces that will be exerted to bring
about a compulsory, federal health insurance
system. While cutbacks in the federal budget can
be expected to limit the expansion of health care
programs of the Medicaid or assistance type, at
least for the immediate future, there is no reason
why the Department of HEW could not promote
a contributory program, once its internal prob-
lems with the administration of Medicare and
Medicaid have been contained.

In view of the outcome of the 1968 presiden-
tial election, it would be foolhardy to venture an
opinion on how rapidly government at the fed-
eral, state, and local level will increase its finan-
cial, organizational, and administrative involve-
ment in the delivery of health services. It would
be equally foolhardy, however, to expect a com-
plete reversal of the trend, rather than a mere
slowing of the pace.

The ultimate fate of public, or consumer, par-
ticipation in health care planning, as embodied
in the Partnership for Health Amendments, is also
difficult to foretell at this early date. There is
growing evidence, however, that government
health agencies will resist more than token in-
volvement of the public in planning, as they
have resisted that of organized medicine. It be-
gins to appear that the so-called Areawide Com-

prehensive Health Planning agencies will be mere
reshufflings of the same groups and individuals
who are now influential with government health
and hospital administrative authorities. If the
communities and the medical profession permit
this to happen, planning for health services may
be dominated or completely controlled by gov-
ernment health agencies and officials. As a con-
sequence, strong pressure would be exerted for
the expansion of prepaid group practice while
private solo and group practice, based as they
are on fee-for-service payments, would become
the targets for regulation and fee control. The
importance of properly balanced representation
of all competent and interested segments of the
population on comprehensive health planning
bodies is quite clear, since only such broadly
based organizations will permit the various
health service delivery systems to prove their
worth in coompetition with one another. Specific
recommendations on this matter will be made in
a later portion of this report. At this time, the
Committee merely wishes to identify a trend
which may affect the course of medical practice
in the future.

It is worth noting that government officials in
the health field are frequently unresponsive to
the policies, opinions, and advice of organized
medicine. Whether or not they succeed in domi-
nating health planning councils, their attitudes
and recommendations will be given much weight
in the framing of legislation relating to health
services. Organized medicine, to counter or con-
tain their effect, will find it necessary to devise
ways of exercising its own influence in the forma-
tive stages of health legislation. In addition,
since health and welfare officials administer gov-
ernment programs, medical societies, at their re-
spective levels, must develop a capacity for
prevailing on them to modify their administrative
policies and regulations when such modification
is indicated.

HOW A PROFESSIONAL ASSOCIATION
CAN EXERT INFLUENCE ON LEGISLATION
AND ADMINISTRATION

At this juncture, it is pertinent to consider how
influence can be brought to bear by an organiza-
tion such as ours, the points at which it can be
applied, and the conditions necessary for it to
produce the desired results. It is clear that no
medical society or other professional association
can be a prime mover in the socio-economics of
the health service system, since it can neither
legislate in this field nor administer government
programs. The Association can therefore expect
to exert an effect directly proportional to its ca-
pacity for influencing legislation on the one hand,

23 1

APRIL 1970

HOUSE OF DELEGATES / Continued

and the administration of existing programs on
the other.

INITIATION OR MODIFICATION OF
HEALTH LEGISLATION

With regard to health legislation, there are
three useful modalities for the application of the
medical profession’s influence. The first of these
is the persuasion of legislators to adopt one par-
ticular course or abandon another. Persuasion is
usually exerted through the instrumentality of
legislative counsel or what is more vulgarly and
colloquially known as a lobby. The results
achieved by this means depend on the soundness
of the Association’s recommendations, the per-
suasiveness and validity of its supporting argu-
ments, and the probable impact of the proposed
action on public welfare and public opinion. In
addition, the outcome depends on the prestige of
the organization and the degree of friendship and
respect its representative enjoys among influential
legislators. Generally, when the issues in ques-
tion are highly controversial, persuasion, in its
pure form, is ineffective and either gives way or
shades off into the second modality, political pres-
sure. This can take two forms, the first of which
is direct political action intended to affect the out-
come of elections for public office. In theory, such
action is effective because it can exert a favor-
able or unfavorable influence on the political ca-
reers of individual legislators. The actual im-
pact of political action on legislation is extreme-
ly difficult to assess but it must be proportionate
to the legislators’ appraisal of the weight of sup-
port or opposition they may expect as a result of
the positions they take on the organization’s
requests and recommendations. Although political
action of this type is neither appropriate nor legal
for a tax exempt association such as the AMA, it
is both proper and legal for separate organiza-
tions of physicians such as the national and state
PAC groups.

Political pressure can also be generated by
arousing substantial public, i.e., voter, support
for one or more of the Association’s policies and
clearly demonstrating the strength of that support
to legislators and public officials.

This leads to the third and final modality, pub-
lic relations, which is not only a principal endeav-
or in itself but is also a powerful support mech-
anism for persuasion and political pressure.
Ideally, PR programs should create the general
belief that the objectives of the Association are
unselfish and in the best interest of the public.
They should also establish the Association’s com-

petence in general and, more specifically, on the
issue immediately in question. To the extent that
PR programs achieve these goals and enhance
the legislators’ appraisal of the Association’s mo-
tivations and effectiveness, they are capable of
affecting legislation relating to health care. In
addition, insofar as public relations efforts en-
gender popular support for a specific measure
advanced or supported by the Association, they
augment the effects of persuasion and political
pressure for its adoption.

MODIFICATION OF PROGRAM
ADMINISTRATION

If we turn from legislation to a consideration
of how the administration of existing govern-
ment health programs can be changed or modi-
fied, we find that at least one new modality must
be added to the Association’s armamentarium.

The administrators of public programs are usu-
ally health or welfare officials who are appointed
rather than elected, and who are therefore not
amenable to direct political pressure. It is true
that this type of influence can be brought to bear
on the elected officials who determine or have
ultimate authority over program operation, but
experience has shown that it is extremely difficult
to achieve desired modifications by this means.
Except under very special circumstances, political
pressure is not effective in the general area of
program administration.

Public relations measures are also of limited
value in this particular application. On issues of
great importance that are easy to explain to the
lay public and that command good coverage by
the news and information media, it is possible to
raise enough public support to cause appointed
officials to modity their regulations, either spon-
taneously or at the behest of the administration
that controls them. Such issues are exceptional,
however, and public relations therefore consti-
tutes a weak device for bringing about modifica-
tions in government health programs.

Persuasion is the last of our previously dis-
cussed three mechanisms and in this area of en-
deavor it is the poorest instrument of all. Be-
cause of the very nature of their motivations, in-
terests, and objectives, there is almost invariably
some degree of friction and antagonism between
health and welfare officials and the medical so-
cieties that correspond to their jurisdictions. With
few exceptions, program administrators have
proven to be refractory to the arguments, advice,
and even to the demands of organized medicine.

Thus, all the mechanisms that are useful in
exerting influence over legislation are of limited
efficacy, or completely ineffective, when applied

232

JOURNAL MSM A

"All Interns are Alike"

: stands to reason. They all go through the same train-
lg; they all have to pass the same tests; they all have
} measure up to the same standards; they all are
nderpaid, too. Therefore, all interns are alike.

That's utter nonsense, of course. But it's no more
onsensical than what some people say about aspirin,
lamely: since all aspirin is at least supposed to come
p to certain required standards, then all aspirin
ib lets must be alike.

Bayer's standards are far more demanding. In fact,
lere are at least nine specific differences involving
urity, potency and speed of tablet disintegration.

These Bayer® standards result in significant product
benefits including gentleness to the stomach, and
product stability that enables Bayer tablets to stay
strong and gentle until they are taken.

So next time you hear someone say that all aspirin
tablets are alike, you can say, with confidence, that it
just isn't so.

You might also say that all interns aren't alike,
either.

HOUSE OF DELEGATES / Continued

to the modification of program operation. A new
dimension must therefore be added to medical
society activities in their relationships with the
administrative branches of government. That di-
mension is negotiation.

Negotiation applies to all aspects of program
operation including not only professional fees but
also the rules, regulations, and procedures that
establish the conditions under which physicians
render their services. Several factors determine
the success of the medical societies in negotiating
agreements. The terms and conditions they seek
must be justifiable and reasonable as far as fees
are concerned, and they must be consistent with
the public interest and the interests of the bene-
ficiaries with regard to regulations and proce-
dures. Another extremely important determinant
is timing. Administrative modifications must be
sought early in the development of a program,
preferably before it is put into effect. Ideally, the
request for such changes should also be made at
a time when their implementation is not political-
ly embarrassing to the administration in power.

Even if they meet all these conditions, how-
ever, the medical societies’ arguments and re-
quests are rarely accorded serious consideration
unless the negotiators can deal from a position of
strength. One possible source of that strength is
manifest public sympathy for the Association’s
position. Such support is only rarely attainable
because the issues at stake are often technical
in nature and of no immediate interest to the
public. The principal and basic source of strength
for negotiators lies in their being able to demon-
strate that they have the backing of the majority
of the members they represent and that, on their
recommendation, those members will refrain
from participating in the program, thereby im-
pairing its usefulness or defeating its purpose. It
is both distasteful and self-defeating, however, for
a medical society to use threat as a weapon when
dealing with matters that impinge directly on the
public health and welfare. Recent rounds of wage
discussions and strikes among civil service work-
ers, particularly in the State of New York, have
made it evident that in the public or private do-
main, negotiations based on the threat of pub-
lic inconvenience or peril are intolerable. It
would certainly be useless, as well as contrary to
the medical profession’s tradition, for physicians
or their representatives to adopt the trade union
“bargaining” approach.

This does not mean, however, that negotiation
is useless as a means of promoting or securing

suitable conditions and reimbursement for phy-
sicians. It merely means that we must find an
alternative to force or pressure to reinforce our
claims. The only logical alternative is to estab-
lish a climate in which medical associations and
government agencies may agree to negotiate with
mutual respect and a recognition of the communi-
ty of their goals. Government has a powerful in-
centive to establish a smooth and cooperative re-
lationship with the medical profession since phy-
sicians are required to implement all health pro-
grams and control the utilization of facilities and
non-medical health personnel. There is therefore
no reason why government should raise obstacles
to negotiation once it is convinced that the so-
cieties, with the full backing of their members,
are prepared to negotiate seriously on the basis
of accepted principles and sound data. If this
type of relationship is to be established success-
fully, it will be necessary for the medical societies
to create and train groups for that purpose and
for counterpart groups or agencies to be formed
by government. These must then meet to lay
down the principles, ground rules and procedures
that will govern their relationship and to de-
fine their objectives. The process will take time
and it is for that reason that the Committee has
emphasized the importance of organizing teams
and the urgency of making a beginning.

Physicians sometime have difficulty in under-
standing why, if the usual, customary, prevailing
and reasonable concept is preserved, there should
be a need for negotiation. Nevertheless, the fact
that they shy away from the term “prevailing”
and prefer to omit it from their writings and dis-
cussion indicates that there is either a conscious
or instinctive recognition that the prevailing fee
is actually an unpublished maximum fee schedule
which can be set at any percentage of customary
fees. It therefore follows that at some time ne-
gotiations to set the percentile of prevailing fees
will become necessary. The parting remarks of
the outgoing Secretary of Health, Education,
and Welfare substantiate this belief. If existing
medical societies fail to prepare themselves for
negotiation, other groups will inevitably take over
that function and thereby undermine the societies’
membership and influence.

Obviously, the need at the AMA level is not
nearly as acute at it is in the lower echelons of
medical society organization, but even national-
ly it is quite conceivable that the Association will
find it necessary to make agreements with gov-
ernment on the operation of health programs.
That necessity should be anticipated and provid-
ed for.

234

JOURNAL MSMA

LEGISLATION: ESSENTIAL CONDITIONS
FOR SUCCESSFUL PUBLIC RELATIONS
AND LEGISLATIVE PROGRAMS

Having examined the general mechanics of ex-
erting influence on legislation, the major area in
which the Association must function, let us con-
sider how our public relations and legislative ex-
perts must be armed and what must be the char-
acteristics of the policies and programs they are
required to promote.

The most important single requirement is that
the organization they represent be respected for
its motivations and purposes. This can happen
only if the AMA has a general policy or avowed
purpose that is clearly stated, is understood by
legislators and the public alike, and is demon-
strably in the public interest. The Committee
proposed the adoption of such a statement in the
first section of this report, i.e.:

“To endeavor, by all appropriate means, to
make health services of high quality available
to all individuals, in a dignified and acceptable
manner, regardless of their ability to pay for
those services, the source of the payment, their
social status, or their ethnic origin. The Amer-
ican Medical Association has the duty to guide
and assist the medical profession in the at-
tainment of this objective.”

The adoption of this or a similar statement is
the first step toward an action program for the
Association. Subsequent policies on more specif-
ic issues must also have certain characteristics if
they are to be successfully promoted. They should
be innovative to the greatest extent possible and
should be directed toward solving problems and
correcting deficiencies in health care that have
been identified by the Association itself. They
must be based on objective analyses of factual
information rather than be subjective and emo-
tional responses to proposals made by officials or
legislators. All policy statements must be con-
sistent with one another and with the objectives
set forth in the statement of the Association’s
purposes.

Even if the policies meet all these criteria,
however, they will not necessarily be received fa-
vorably by legislators. Since it is important to the
AMA’s public stature that it be associated with
as few failures as possible, each of its statements,
policies, and actions in the field of health ser-
vice legislation should be judged by the follow-
ing four tests:

( 1 ) Is it in the public interest or interpretable
as such?

(2) Is it politically advantageous, or at least
innocuous, for the legislators to adopt?

(3) Will it have public support or, if contro-

versial, is it likely to have the support of a ma-
jority of politically influential groups?

(4) Is it consistent with the previous policies
and pronouncements of the Association on the
same or similar issues?

The relative weight ascribed to these tests will
vary with the issue in question but all are op-
erative to some degree. It is true that from time
to time the Association may be impelled to pro-
pose a course of action that, while in the public
interest, does not qualify for support by the other
three criteria. This should be done only in those
instances when, after careful deliberation, the im-
portance of the matter seems to justify taking a
calculated risk.

It is instructive to examine the AMA’s course
of action on Medicare in the light of these ob-
servations. The Association’s opposition was more
emotional than objective and was at least partial-
ly predicated on an underestimation of the prob-
lems faced by the elderly in the financing of
health care. In spite of its honest motivation, the
Association’s position was easily distorted to give
the impression that physicians were opposed to
the provision of needed aid to the elderly for
selfish reasons, obviously not in the public inter-
est. In addition, the AMA’s policy did not have
the support of a majority of the populace and
would therefore have been a liability for any
legislator to espouse. About the only criterion it
did meet was that of consistency with earlier
positions on the same subject.

This is not to say that the policy of the Asso-
ciation at that time was necessarily wrong in the
light of the few facts that were then available or
that it should not have been adopted. It is mere-
ly to point out that failure was predictable. In
retrospect, a more useful and practical approach
might have been to investigate more thoroughly,
accept the principle involved, as we ultimately
did, and then act to modify the program as in-
novators rather than critics and opponents. Since
the formulation of sound policy by the organiza-
tion is the very essence of successful legislative
activity, let us now examine the structure of the
Association to determine how well it is suited for
this function.

STRUCTURE OF THE ASSOCIATION

The AMA is a rather loose federation of fifty
state medical societies and the medical societies
of the District of Columbia, U. S. Virgin Islands,
Canal Zone, and the Associated Commonwealth of
Puerto Rico. These societies are known as the
constituent or state associations. They are as-
signed one or more delegates to the House of

APRIL 1970

235

HOUSE OF DELEGATES / Continued

Delegates of the AMA in proportion to the size
of their memberships. In addition, Scientific Sec-
tions of the Association are allotted one delegate
each, as are the Armed Services, the Public
Health Service, and the Veterans Administration.
These members of the House are voting dele-
gates. Other ex-officio members have voice but no
vote.

THE HOUSE OF DELEGATES

The House of Delegates is the final authority
on all actions and policies of the Association.
When it is in session, it acts on all resolutions in-
troduced by member delegates, reports of the
Board of Trustees and Standing Committees of
the House. Finally, the House of Delegates elects
the Officers and Trustees of the AMA. This body
is therefore the supreme authority and, if it met
continuously, would exclusively govern all of the
organization’s policies and functions. Since it is
not in continuous session, however, it is the ma-
jor rather than the sole determinant of AMA
policy.

The House of Delegates meets twice a year in
working sessions of approximately three days,
during which time it decides the Association’s re-
sponses to the important issues and situations it
faces. In spite of meticulous advance prepara-
tion by staff and an excellent reference commit-
tee system, this is too short a time for it to digest,
evaluate and act on myriad complex matters,
most of which vitally affect the health of the pub-
lic and the practice of medicine. In the time
available, individual members cannot consider
each issue that comes before the House in the
depth that its importance may require. At the
best a delegate can attend one or two reference
committee hearings and can therefore become
thoroughly informed on only a portion of the is-
sues on which he will be required to vote. The
effect of this on the quality of policy making is
obvious.

The AMA’s essentially political and demo-
cratic nature also has an influence on the actions
of the House. Aside from staff and appointed
committee members, the Association consists of
office holders who are elected to represent the en-
tire membership and take action in their name.
The delegates are elected by their own state as-
sociations, while the Officers and Trustees are
elected by the House of Delegates.

If delegates deviate too frequently from po-
sitions taken by their state associations, they are
likely to lose their support at home and fail to be
re-elected. In addition, if they oppose the major-

ity in the House too often, especially on certain
vital issues, they may incur the penalty of being
denied further advancement in the Association.
In either case, they lose the opportunity of con-
tinued or increased participation in a field of ac-
tivity that is of profound interest to them, to
which they have devoted much time and be-
lieve they can make significant contributions.
Under these conditions, they may be swayed to
vote as they are mandated or to be influenced by
the majority opinion against their personal judg-
ment.

To fully appreciate the factors that shape the
policies adopted by the House of Delegates, it is
also necessary to understand the characteristics
of the delegates themselves, insofar as a complex
group such as this can be considered to have
group characteristics. In general, most of them
have successful practices with patients derived
from the middle and upper income brackets. The
majority tend to be conservative in their political
and social philosophies and, almost without ex-
ception, are deeply concerned with preserving the
traditions of their profession and their time-hon-
ored relationships with their patients. They there-
fore resent criticism of present methods of ren-
dering medical care and programs that permit in-
dividuals or agencies to intrude between them
and their patients.

These characteristics must be equated with
current trends if the reactions of the delegates are
to be fully understood. The public and the vari-
ous legislatures, spurred by the enormous strains
created by the disparity between limited health
facilities and personnel and unprecedented in-
creases in demand, are inclined to place great
emphasis on such considerations as cost, quality
of services, and the logistics of delivery. They are
attempting to control these factors by intervening
more frequently and more directly in the plan-
ning and regulation of health care, often to the
exclusion of medical and other health profes-
sional associations.

Under these circumstances, issues in the socio-
economics of health care and the organization of
delivery systems for health services have a high
emotional content for the delegates. The House
has on occasion reacted to matters of this nature
in a reflex fashion, rather than deliberately, with
considered and dispassionate judgment. As a re-
sult, positions have been assumed that were in-
consistent with the medical profession’s overall
objectives and that were widely misinterpreted as
being a guild type of response motivated by self-
ish interests. The adoption of such policies trau-
matizes the Association’s public relations and di-
lutes the effect of its legislative activities. The

236

JOURNAL MSM A

Remember how great
milk of magnesia tasted ?

Almost as good as castor oil.

But now you can spare the
taste buds and spoil the patient with a
modern Dulcolax tablet or suppository.

And Dulcolax works so pre-
dictably that the time of bowel move-
ment can often be predicted. Tablets
taken at night usually produce a bowel
movement the following morning.
Suppositories generally work in 15
minutes to an hour.

For preoperative preparation,
a combination of tablets at night and a
suppository the next morning usually
cleans the bowel thoroughly.

Dulcolax suppositories may
be particularly helpful when straining
should be avoided, as in postoperative
care. Keep in mind, however, that the
drug is contraindicated in theacute sur-
gical abdomen.

Dulcolax8. . . it’s predictable

bisacodyl

license from Boehringer Ingelheim G.m.b.H. Geigy Pharmaceuticals, Division of Geigy Chemical Corporation, Ardsley, New York 10502

DU-7015

A once-popular treatment for back pains
was to have the seventh son of a seventh son
stand or walk on the patient's back.

For headache, a sovereign remedy was
to wear a snakeskin round one's head.

The pain of earache was allegedly relie'
by holding a hot roasted onion to the ear

A realistic
approach

to pain
relief

‘Empirin’*

Compound with Codeine

Phosphate gr. 1/2 No. 3

Each tablet contains:

Codeine Phosphate gr. 1/2 (Warning-
May be habit forming), Phenacetin gr. 2 1 / 2,
Aspirin gr, 3 1 / 2, Caffeine gr. 1 / 2.

keeps the promise

oi pain, relief

'B.W. & Co.' narcotic products are

Class ”B", and as such are available on oral

prescription, where State law permits.

BURROUGHS WELLCOME & CO. (U.S.A.) INC.
.MIC Tuckahoe, N.Y.

I N ASTH M A JL optional

in emphysema f i r therapy

■

All Mudranes are bronchodilator-mucolytic in action, and
are indicated for symptomatic relief of bronchial asthma,
emphysema, bronchiectasis and chronic bronchitis. MU-
DRANE tablets contain 195 mg. potassium iodide; 130 mg.
aminophylline; 21 mg. phenobarbital (Warning: may be
habit-forming); 16 mg. ephedrine HC1. Dosage is one tablet
with full glass of water, 3 or 4 times a day. Precautions are
those for aminophylline-phenobarbital-ephedrine combina-
ations. Iodide side-effects: May cause nausea. Very long
use may cause goiter. Discontinue if symptoms of iodism
develop. Iodide contraindications: Tuberculosis; preg-
nancy (to protect the fetus against possible depression of
thyroid activity). MUDRANE-2 tablets contain 195 mg.
potassium iodide; 130 mg. aminophylline. Dosage is one tablet
with full glass of water, 3 or 4 times a day. Precautions are
those for aminophylline. Iodide side-effects and contra-
indications are listed above. MUDRANE GG tablets
contain 100 mg. glyceryl guaiacolate; 130 mg. aminophylline;
21 mg. phenobarbital (Warning: may be habit-forming);
16 mg. ephedrine HC1. Dosage is one tablet with full glass of
water, 3 or 4 times a day. Precautions are those for amino-
phylline-phenobarbital-ephedrine combinations. MUDRANE
GG-2 tablets contain 100 mg. glyceryl guaiacolate; 130 mg.
aminophylline. Dosage is one tablet with full glass of water,
3 or 4 times a day. Precautions: Those for aminophylline.
MUDRANE GG Elixir. Each teaspoonful (5 cc) contains
26 mg. glyceryl guaiacolate; 20 mg. theophylline; 5.4 mg.
phenobarbital (Warning: may be habit-forming); 4 mg. ephe-
drine HC1. Dosage: Children, 1 cc for each 10 lbs. of body
weight; one teaspoonful (5 cc) for a 50 lb. child. Dose may
be repeated 3 or 4 times a day. Adult, one tablespoonful, 4
times daily. All doses should be followed with Yi to full glass
of water. Precautions: See those listed above for Mudrane
GG tablets.

MUDRANE— original formula

First choice

MUDRANE-2

When ephedrine is too exciting
or is contraindicated

MUDRANE GG

During pregnancy or when K.I. is
contraindicated or not tolerated

MUDRANE GG-2

A counterpart for Mudrane-2

MUDRANE GG ELIXIR

For pediatric use

or where liquids are preferred

Clinical specimens
available to physicians.

WILLIAM P. POYTHRESS & COMPANY, INC., RICHMOND, VIRGINIA 23217

3

1 '

o

According to the Framingham Heart Study,
the obese face:

86% greater risk of angina pectoris,

82% greater risk of diabetes,

71% greater risk of coronary heart disease.

Obesity may aiso aggravate osteoarthritis,
fiat feet, intertriginous dermatitis, varicose
veins, and ventral or diaphragmatic hernias

tou are considering weight reduction, consider

phenmetrazine hydrochloride
Endurets®

prolonged-action tablets

Often effective

Controlled studies in a general patient popu-
lation have shown that when Preludin is used
with diet, the rate of weight loss exceeds
that obtained by placebo and diet.

Long acting

Slow, even release of the active principle
usually suppresses appetite continuously for
about 12 hours.

Once-a-day dosage

One Endurets tablet after breakfast. It helps
reduce weight and costs, conveniently.

For contraindications, warning, precautions,
and adverse reactions, please see the full
prescribing information.

It is summarized on this page.

Where there’s no will there’s a therapeutic way.

*Among persons 20% or more
overweight as compared with
median weight for persons of
like height and sex.

1. Kannel, W.B., et at.: Circula-
tion 35:734, 1967.

2. Thomas, H.E., Jr., et at.: Med.
Times 95:1099, 1967.

3. Albrink, M.J., in: Beeson,

P.B. & McDermott, W. (eds.):
Cecii-Loeb Textbook of Medicine,
ed. 12, Phila.: W.B. Saunders
Co., 1967.

Preludin®

phenmetrazine hydrochloride

Preludin is indicated only as an
anorexigenic agent in the treat-
ment of obesity. It may be used in
simple obesity and in obesity
complicated by diabetes, mod-
erate hypertension (see Pre-
cautions), or pregnancy (see
Warning).

Contraindications: Severe
coronary artery disease, hyper-
thyroidism, severe hypertension,
nervous instability, and agitated
prepsychotic states. Do not use
with other CNS stimulants,
including MAO inhibitors.
Warning: Do not use during the
first trimester of pregnancy un-
less potential benefits outweigh
possible risks. There have been
clinical reports of congenital mal-
formation, but causal relation-
ship has not been proved. Animal
teratogenic studies have been
inconclusive.

Precautions: Use with caution in
moderate hypertension and
cardiac decompensation. Cases

involving abuse of or depend-
ence on phenmetrazine hydro-
chloride have been reported. In
general, these cases were
characterized by excessive
consumption of the drug for its
central stimulant effect, and have
resulted in a psychotic illness
manifested by restlessness, mood
or behavior changes, hallucina-
tions or delusions. Do not exceed
recommended dosage.

Adverse Reactions: Dryness or
unpleasant taste in the mouth,
urticaria, overstimulation,
insomnia, urinary frequency or
nocturia, dizziness, nausea, or
headache.

Dosage: One 25 mg. tablet b.i.d.
or t.i.d. Or one 75 mg. Endurets
tablet a day, taken by mid-
morning.

Availability: Pink, square, scored
tablets of 25 mg. for b.i.d. or
t.i.d. administration, in bottles of
100 and 1000.

Pink, round Endurets® prolonged-
action tablets of 75 mg. for
once-a-day administration, in
bottles of 100 and 1000.
(B)R3-46-560-B

For complete details, please see
full prescribing information.

Under license from
Boehringer Ingelheim G.m.b.H.

Geigy Pharmaceuticals (
Division of

Geigy Chemical Corporation
Ardsley, New York 10502

n*TiM

HOUSE OF DELEGATES / Continued

periodic occurrence of this type of reaction, how-
ever, is almost inevitable, given the composition
of the House and the nature of its operation.

THE BOARD OF TRUSTEES

In order that the Association may function be-
tween the sessions of the House of Delegates, a
fifteen member Board of Trustees is given interim
powers. Twelve Trustees are elected by the
House of Delegates, in annual groups of four,
for three year terms. The other three voting mem-
bers are the President, the President-Elect, and
the Immediate Past President.

By the nature of its powers and responsibil-
ities, the Board of Trustees exerts a second and
potent influence on the formulation of policy, in
spite of the fact that its decisions are technically
subject to ultimate ratification by the House. The
Board meets periodically to act for the AMA on
routine matters and on special call of the chair-
man to decide more urgent and immediate ques-
tions. As background, the Trustees have a con-
stant flow of information and reports from the
Councils, Committees, commissions, and divi-
sions, and they usually have sufficient time for
thorough exploration of issues before taking ac-
tion. In this they have some advantage over the
House of Delegates in policy making.

The Trustees, however, share the general char-
acteristics of the delegates as far as political and
social philosophy are concerned. In addition, the
Board, in its interregnun, cannot help but con-
sider and be influenced by the probable attitude
of the House of Delegates on its actions. This
concern is reinforced by the political reality that
twelve of the Trustees, or as many as are eligible,
are re-elected by the House, on the nomination
of the delegations from their home state societies.

A final determinant of the nature of the
Board’s actions and policies lies in the internal
relationships and balances of power among the
individual Trustees. These, of course, are impos-
sible to categorize or measure, but the extent of
their effect becomes apparent from time to time.

THE PRESIDENT

The office of the President is a third source of
policy determination for the Association. Since
the President is elected for a term of one year, it
is rare for him to make a major change in the
organization’s directions and goals, though he
could conceivably do so by exerting enough lead-
ership to prevail on the Trustees and the House
of Delegates. On the other hand, the President is
generally considered to be the spokesman for the

Association and although by custom and tacit
agreement he usually adheres to the positions
taken by the House and the Board of Trustees,
he is under no compulsion to do so. He is subject
to no external influence and, since he is a free
agent in enunciating his own beliefs and prin-
ciples, he can exert an appreciable effect on the
Association’s policy from the public relations
standpoint, especially if he departs from previous
positions the AMA has taken. Finally, of course,
the President does have the additional influence
of being one member of the fifteen member
Board of Trustees.

THE EXECUTIVE STAFF

It is traditional for executives of an organiza-
tion such as ours to disavow any desire to play a
role in policy making. There is, however, no
question that the Executive Vice President and,
to a lesser extent, the Assistant Executive Vice
President, can have a profound influence on the
process. The magnitude of that influence depends
on the motivations of the individuals, the nature
of their relationships with each other and with
the Officers, Trustees, and the House of Dele-
gates, their leadership qualities, and their aggres-
siveness. Since they usually have tenure over a
number of years, they have the opportunity to be
influential in decision making without overtly
over-stepping their authority. Again, the precise
determination of the importance and effect of so
impalpable force is impossible, but no student of
the AMA’s history can doubt its existence and
potential.

It is evident, therefore, that the AMA’s pol-
icies come into being as the result of a constant
interplay of the authorities and decisions of four
separate groups or individuals, rather than from
a single source. This decentralization of function
introduces an element of uncertainty and incon-
sistency into the Association’s position statements.

Many statements about the Association, ema-
nating from the news media, labor unions, econ-
omists, and even some physicians, attest to a be-
lief that the AMA places the financial welfare of
its members above the interests of the public.
Similarly these same sources have branded the
AMA as reactionary and of having purely guild
objectives. Ill-founded though they are, the mere
existence of such attitudes hampers the organiza-
tion in the attainment of its legitimate goals. At
this point therefore it is appropriate to decide
whether the AMA can reverse these public opin-
ions and meet its obligations to its members and
the public as it is presently organized, or whether
it must undergo a fundamental alteration in struc-
ture.

238

JOURNAL MSM A

THE

COST OF

AM BAR
EXTENTABS

FAT PEOPLE ARE FAR
MORE APT TO DIE
SUDDENLY THAN
THIN PEOPLE I A \

IS APPROXIMATELY 10%T040%

LESS THAN THAT OF OTHER LEAD-
ING APPETITE SUPPRESSANTS

AN IMPORTANT FACTOR
IN LONGTERM

LEVI STRAUSS SCO. WILL
GIVE A FREE PAIR OF LEVI’S
TO ANYONE WHO MEASURES

OUT TO A .

(INCH WAIST)

DRINKING TOA
LADY'S HEALTH,
QUAFFED ONECUP
OF WINE FOR EVERY
LETTER OF HER NAME)

Control food and mood
all day long with
a single morning dose

AMBAFT2

EXTENTABS’

methamphetamine HCI 15 mg.,
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One Ambar Extentab before break-
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BRIEF SUMMARY/Indications: Am-
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offset emotional reactions to dieting.

Contraindications: Hypersensitivity
to barbiturates orsympathomimetics;
patients with advanced renal or
hepatic disease. Precautions: Ad-
minister with caution in the presence
of cardiovascular disease or hyper-
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or excitement occasionally noted,
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has been reported rarely. See pack-
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Also available: Ambar #1 Extentabs®
— methamphetamine hydrochloride
10 mg., phenobarbital 64.8 mg. (1 gr.)
(Warning: may be habit forming).

HOUSE OF DELEGATES / Continued

MANAGEMENT SURVEY

The Committee was aware of the management
survey being conducted by the firm of Cresap,
McCormick and Paget. At the time of this writ-
ing, its preliminary report has just been distribut-
ed.

As anticipated, the report does not call for a
fundamental or drastic reorganization of the As-
sociation. It is interesting to note, however, that
the survey team, as the Committee has done,
identifies the weaknesses inherent in a division of
responsibility and authority in policy making and
programming. The report emphasizes the neces-
sity for centralized planning in accordance with
established priorities, again a matter of major
concern to the Committee. Finally, the defini-
tions of the Association’s aims and objectives, as
developed on pages 10 and 11 of the preliminary
report, are in general agreement with the Com-
mittee’s own thinking and recommendations.

The Committee does not at this time wish to
comment further on the preliminary survey re-
port. Knowing that a professional management
study was in the process, and assuming that the
consultants would concern themselves chiefly with
the administrative branch of the Association, our
group saw no reason to evolve its own recom-
mendations on internal administrative balances.
It preferred to place emphasis on the Associa-
tion’s external relationships with various seg-
ments of the public and with the constituent and
component medical associations.

Furthermore, since both the current manage-
ment survey group and the previous survey com-
mittees of the Board of Trustees have devoted
considerable attention to the number of councils,
commissions, and committees and the duplication
of some of their activities, the Committee on
Planning and Development refrained from going
over that ground again. This report and the man-
agement study report therefore have different
orientations but, in the few areas in which they
overlap, there is no fundamental conflict in the
recommendations made.

CONSIDERATIONS FOR AND AGAINST
STRUCTURAL REORGANIZATION

OF THE AMA

The diminution of effectiveness imposed by
the Association’s democratic and political nature
was discussed earlier in this report. Any plan for
reorganization designed to eliminate these de-
ficiencies, however, would of necessity curtail
or eliminate the autonomy of constituent asso-
ciations, proportional representation and majori-
ty rule in the House of Delegates, and the priv-

ilege of free expression in an open forum. These
positive values, which are basic elements of the
Association’s present structure, would be difficult
or impossible to duplicate in any other system.
The Committee is of the opinion that it is im-
portant that they be preserved. It therefore seems
necessary to accept some of the penalties of our
present organization and to minimize them, inso-
far as possible, by improved operations and more
effective working relations with the constituent
medical associations. This does not preclude the
adoption of the recommendations of the manage-
ment survey team or rearrangements of the ad-
ministrative staff and reallocations of responsi-
bility.

The Committee therefore recommends:

That the present structure of the Association
be retained and that it be strengthened by im-
provements and modifications in its function.

CHANGES IN ASSOCIATION ATTITUDE

Improvements in the AMA’s performance will
require that it alter its approach to the public
and to its constituent associations. At the risk of
being repetitious, the Committee would again
emphasize that the Association must abandon its
public and exclusive support for existing delivery
systems and avoid use of the terms “private prac-
tice,” “fee-for-service payment,” and “free
choice.” The Committee is keenly aware of the
virtues of many of our present methods of prac-
tice but their importance has not yet been proven
to the public. Arguments directed toward estab-
lishing what has become almost a medical mys-
tique fall on deaf ears in an era when a sub-
stantial number of our population depend on gov-
ernment assistance to buy health services and
must, with the benefits provided, compete with
other segments of society for services that are
costly and in short supply. Until and unless the
Association addresses itself publicly, actively, and
objectively to the resolution of the very concrete
problems that exist in health care, its attempts to
justify present delivery systems and payment
mechanisms will be incomprehensible both to the
public and government and will be interpreted as
self-seeking on the part of the profession. The
Association can and should strive to preserve
those features of medical practice that it consid-
ers important, but the justification for so doing
must be based on proofs of value that are mean-
ingful to the lay public. To this end, it has al-
ready been recommended that the Association
actively identify problem areas in health care and
make positive and realistic recommendations for
the achievement of immediate and long range
improvements.

240

JOURNAL MSMA

THE ASSOCIATION’S ATTITUDE TOWARD
THE CONSTITUENT ASSOCIATIONS

Within the limitations of the AMA’s Constitu-
tion, Bylaws, and ethics, the state medical asso-
ciations are completely autonomous. This auton-
omy, coupled with the fact that the members of
the House of Delegates, which is the ruling body
of the organization, are elected by the constituent
societies, has made the AMA hesitant in offering
positive action programs and suggestions on re-
organization to the states. Nevertheless, the state
associations do need expansion and reorganiza-
tion along lines that will be developed later in
this report and the AMA must assume the lead-
ership in bringing it about.

The recommendation has appeared repeatedly
in this report that the Association gather data
from the state and county societies on one aspect
or another of health care with the purpose of
identifying problems and formulating recommen-
dations for their solution. The point has been
made that all medical society activities, at the
national, state, and local level, are dependent on
accurate information and statistics on all factors
influencing health care. At the 1968 Clinical
Convention, the House adopted a resolution
mandating the Board of Trustees to expedite and
expand programs, and where necessary, to create
new ones to analyze health care costs and ex-
penditures and to disseminate the data so col-
lected. This was directed at administrative costs,
only one small facet of the total problem, but it
did represent the recognition by the House of the
Association’s need for data.

Studies of the type called for in the resolution
can be accomplished in one of two ways. They
can be purchased from management consultant
organizations on a fee-for-service basis, or they
can be self-conducted. For the general purposes
of the AMA, the management consultant route
is excessively costly and is of limited value be-
cause studies conducted in this manner are di-
rected toward a single issue and, even then, are
episodic rather than continuous. The only advan-
tage offered by survey team studies is that they
are deemed to be objective and uninfluenced by
the interests of the profession. They certainly can-
not begin to provide the constant, current, and
comprehensive substrate of information that the
Association requires. The second alternative is
for the AMA itself to conduct one or more studies
from headquarters. Since it is not presently or-
ganized to do so, it would have to establish a
data center and send out research teams to in-
dividual states and regions. Either the costs of
such an endeavor would be prohibitive or it
would fall short of its purpose.

The most effective and least costly means of
accumulating data on a continuous basis would
be to utilize the personnel and facilities of the
state and county medical societies which would
have to be organized for that purpose. This would
not be as difficult as it might seem at first glance.
State and local medical societies have demon-
strated a growing awareness of the necessity for
involving themselves more deeply in the investi-
gation and planning of health care. It is signifi-
cant that some of the larger medical societies
have already formed divisions for research into
the fundamental problems of the socio-economics
of medicine, medical education, and environmen-
tal factors that affect health. The current climate
will probably make medical societies at lower
echelons receptive to the concept of investing sig-
nificant amounts of money and time for this type
of social research, especially if their efforts are
coordinated through a central agency. Those
states that have too small a membership to do
this alone could join forces on a regional basis to
achieve these ends.

In any event, properly organized, the societies
would form a nationwide network devoted to
data accumulation and analysis. The Associa-
tion’s function should be to promote the forma-
tion of these resources and to establish uniform
standards as to the manner in which data are
accumulated, reported, and forwarded. Even
those county and state societies that are most
jealous of the prerogatives and autonomy will
recognize the advantages offered by this course of
action and will not consider it an invasion of
their rights.

An obvious corollary to this thesis is that the
AMA must become more aggressive in its lead-
ership and work actively to create and coordinate
the facilities and capabilities of these units of or-
ganized medicine so that they may serve a group
function while retaining their individual identities
and purposes. In essence, the AMA must become
a much tighter and more effective federation than
it has been hitherto and the stimulus for such re-
organization must be applied from above down-
ward.

The Committee therefore recommends:

(1) That an immediate survey be conducted
of the state medical societies and, through them,
of the component county medical societies to de-
termine what arrangements they have made, if
any, for the regular collection of data on the so-
cio-economics of health care.

(2) That, on the basis of the information re-
ceived, the AMA develop tables of organization
for research divisions at the state levels and
methods of participation for county societies that

APRIL 1970

241

HOUSE OF DELEGATES / Continued

are in keeping with their resources. The plan-
ning should be developed along lines that are
compatible with the concept of a tight federation
of societies and are least disruptive to research
divisions that are already in existence.

(3) That the plans and tables of organization
in their initial form be circularized among the
state and county medical societies with the rea-
sons for their development and strong recom-
mendations for affirmative action.

(4) That the association hold a series of
working meetings with state and county medical
society executives, individually or in groups, to
further refine the organizational patterns and pro-
cedures that will best serve them in this collective
endeavor.

The mere possession of information is not tan-
tamount to wisdom, however. When this reor-
ganization is accomplished or while it is being
carried out, the AMA must establish an internal
mechanism for analyzing data, identifying prob-
lems, and recommending policy. The Board of
Trustees could be responsible for this function,
although it is doubtful that the Board could, with
all its other duties, devote enough time to it. The
Committee is of the opinion that a planning coun-
cil, divided into committees for the various fields
of inquiry, would suit the purpose better. The
planning council would be required to report and
make recommendations to the Board of Trustees
and the House of Delegates.

The Committee therefore recommends :

That on implementation of the program for
organization and reorganization, a planning coun-
cil with appropriate subcommittees be formed for
the purpose of processing data and formulating
policy recommendations for the consideration of
the Board of Trustees and the House of Dele-
gates.

ACADEMY OF THE PROFESSIONS

If all the recommendations in the foregoing
portion of this report were implemented success-
fully, the AMA would find itself in a greatly im-
proved position to discharge its responsibilities.
It would be possible, therefore, and might be
prudent to conclude the report at this point. The
Committee, however, is influenced by the knowl-
edge that, even with the proposed improvements
in communication and function, the Association
would continue to suffer from an adverse public
appraisal that would hamper its efforts and might
take years of assiduous public relations to over-
come. In addition, since the Association repre-
sents a single health profession, it would prove

unequal to the task of formulating policies and
programs for the multiple disciplines involved in
health care as the Committee has defined it. The
AMA could therefore still not assume the role
that was claimed for it in the planning and de-
velopment of health services:

“That the AMA adopt an active role and
take the initiative in developing all plans and
programs for health care in all their ramifica-
tions, and that it encourage and assist the state
and county medical societies to do the same
at their respective levels.”

If the Association were to attempt to meet the
above objectives as a single organization, the
data and deductions arising from its self-con-
ducted studies, although they might be entirely
accurate and objective, would still, in the public
eye, bear the stigmata of professional prejudice
and self-seeking. The volume and range of the
data would be limited in spite of the participa-
tion and cooperation of the constituent and com-
ponent societies, unless a prohibitively large and
costly surveying agency were established. Finally,
as a result of the complexities of modern health
care, the policies evolved would, of necessity,
require a number of professions, disciplines, and
agencies for their implementation. These groups
would be unlikely to accept or take affirmative
action on policies they had no part in develop-
ing. The AMA has recognized the advantages of
coordinating its efforts with those of other pro-
fessional associations but has not been able to
bring those associations under the umbrella of
its leadership. The liaison committees and other
arrangements that it has created to improve com-
munications and bring about cooperation with
other professional organizations have been un-
satisfactory at best and have not resulted in the
necessary multi-professional approach to the di-
rection of health care. It is quite apparent that
no single professional group can influence the
public or government on any aspect of health
services, not even on those that most vitally af-
fect it individually. The health professional or-
ganizations together, on the other hand, could
have a very weighty influence. It therefore seems
logical for them to unite in a formal organization
to play their part in the planning, legislation, and
delivery of health services, a goal they cannot
achieve individually.

The Committee therefore recommends:

That the AMA sponsor, promote the forma-
tion of, and participate in, a “National Academy
of the Health Professions for Research and Pol-
icy.”

242

JOURNAL MSM A

...to reduce

the hemodynamic “bind”
of constipation
in congestive heart failure

Constipation in the chronic heart failure patient
carries with it the ever-present threat of acute
cardiac decompensation while straining at stool.
In the already weakened, distended heart, a sud-
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maneuver is considered to be the mechanism of
some of the deaths occurring in these cardiac
patients during straining efforts.*

Doxidan is a gentle laxative designed to free your
patient from the hemodynamic consequences of
straining at stool. With a fecal softening agent to
keep the stool soft and easy to evacuate, and with
just enough peristaltic stimulation to urge the
sluggish bowel, Doxidan reduces the hemody-
namic “bind” of constipation.

Composition: Each capsule contains 50 mg. dan-
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cinate.

Dosage: Adults and children gver 12 — one or two
capsules daily. Children 6 to 12 — one capsule
daily. Give at bedtime for two or three days or
until bowel movements are normal.

Supplied: Bottles of 30, 100 (FSN 6505-074-3169)
and 1000 (FSN 6505-890-1247).

est, C. H. and Taylor, N. B.: The Physiolog-
al Basis of Medical Practice, 7th edition,
Mlliams and Wilkins, Baltimore, 1961, p. 480.

HOECHST

PHARMACEUTICAL CO.
Div. American Hoechst Corp.
Cincinnati, Ohio 45229 U.S.A.

C-124

HOUSE OF DELEGATES / Continued

The concept of pooling the resources of sever-
al organizations to serve functions that are useful
to them all is certainly not new. The joining to-
gether of individual agencies into a single entity
to lend their collective weight to their programs,
statements, and opinions is also well established.
In commerce and industry, a number of founda-
tions have been formed for just such purposes.
The proposed academy would be a similar or-
ganization for the health professions.

The Committee is aware that the health scene
in already overcrowded with advisory councils,
commissions, panels, task forces, academies and
ad hoc committees. These have a variety of spon-
sorships and are usually composed of eminent in-
dividuals, expert in one aspect or another of
health care. These serve without pay and meet
from time to time to ponder, discuss, and ulti-
mately to report to and advise the agency or de-
partment of government that created their group.
The overlap of interest of these groups, the dis-
continuity of their efforts, and the limited time
their non-paid experts can devote to them all
militate against their being productive. The net
yield of this type of activity in terms of useful pol-
icy and direction is difficult to assess, but it seems
fair to say that it is disproportionately small when
compared to the time and effort involved. The
Committee emphatically does not wish to add
yet another voice to the babel of confusion that
is already arising from these bodies. Instead, it
wishes to propose a continuing, viable organiza-
tion. geared to the collection, storage, and re-
trieval of data and their conversion into useful,
effective programs and recommendations for the
improvement of health and health services. For
this purpose, the academy must have certain spe-
cific characteristics and relationships with its
sponsors. The following organizational structure
is offered to illustrate some of these characteris-
tics and relationships rather than as a direct rec-
ommendation, since the Committee is aware that
there are many other possibilities. If and when
the Academy concept is adopted, its sponsors will
undoubtedly expect to develop the specific de-
tails of an organization that best meets their
requirements.

ONE POSSIBLE STRUCTURE FOR
THE ACADEMY

(1) That it be a non-profit membership cor-
poration with the sponsoring professional asso-
ciations as members;

(2) That the member organizations be limit-
ed to (a) national associations in the fields of
medicine, nursing, dentistry, osteopathy, medi-

cal education, hospital administration, health and
hospital insurance; (b) national associations rep-
resenting ancillary workers, such as optometrists,
psychologists, pharmacists, and laboratory and
x-ray technicians; and (c) national public health
agencies.

(3) That the academy have a board of direc-
tors numbering approximately forty or fifty mem-
bers, drawn from the participating organizations
partly on the basis of their membership. It is ob-
vious, however, that the number of members
alone is not a sufficient criterion to determine
representation since the different health profes-
sions do not exert the same influence over the
planning, delivery, and cost of health care. It
will therefore be necessary to apply an addition-
al weight or factor to the various organizations
in determining their representation on the board
of directors. This may well be the subject of ne-
gotiation.

(4) That initially the directors be appointed
by their respective member professional associa-
tions for terms of one, two, and three years, so
that the board will ultimately consist of three
classes of directors, each serving terms of three
years.

(5) That tenure on the board of directors be
limited to three terms or 10 years.

( 6 ) That the board of directors elect a chairman
from among its members triennially and that he
be paid a salary commensurate with the claims
made on his time and effort.

(7) That a voting member group be orga-
nized for the purpose of electing directors once
the first, appointed directors have served their
terms. The voting member group should be com-
posed of sixty to seventy-five individuals, thirty-
five to fifty of them to be distributed among the
sponsoring agencies in a proportionate manner,
with the remaining number to be chosen from in-
terested branches of government and appropriate
individuals from the public at large.

(8) That each year a slate of nominees for di-
rectors be proposed by a nominating committee
of the board of directors and that further nomi-
nations, if any, be made from the floor at the an-
nual meeting by any single member of the voting
member group.

(9) That the directors not be employees, ac-
tive officers, or trustees of their own professional
associations.

(10) That the academy retain an executive
officer and indicated supportive staff on a full-
time salaried basis.

(11) That there be the usual division of func-
tion and responsibility between the executive of-
ficer and the board of directors.

244

JOURNAL MSM A

To repeat, the preceding description is intend-
ed to convey the broad organizational outlines of
the proposed academy. More specific details can
be worked out by the sponsoring associations,
once they have accepted the general concept and
agreed to participate. It should be noted, how-
ever, that the type of organization recommended
is designed to preclude domination of the acad-
emy by one or more of its member associations.
It eliminates the possibility of interlocking di-
rectorates and, in general, divorces the academy
completely from the politics of its parent societies.
This is an essential condition without which the
academy could not command the prestige and
public confidence it must have to serve the pur-
poses for which it is founded.

PURPOSES AND FUNCTION

The academy shall collect data relating to
health care on a continuous basis and make pro-
vision for their efficient storage and retrieval. It
shall analyze the import of those data, suggest
policy, and make recommendations on all as-
pects of health care as broadly defined by the
Committee. To accomplish this, it shall identify
weaknesses and deficiencies in health services and
relate them to available funds, facilities, and per-
sonnel to develop specific, practical solutions on
a priority basis. Its reports shall be made to the
parent organizations and all appropriate public
and governmental agencies. They shall be made
public and require only the prior approval of the
board of directors of the Academy.

SCOPE OF ACTIVITY

The following is a partial list of the academy’s
areas of interest, research, and study:

(1) Distribution of health care personnel —
deficiencies in number and type by area.

(2) Distribution and adequacy of health care
facilities by area, to include hospitals, hospital
based or free standing clinics, extended care fa-
cilities, home care services, and clinical labora-
tory services.

(3) Costs, to include medical and other pro-
fessional fees by area or region, hospital and ex-
tended care facility rates, charges for other ser-
vices, drugs, and sick room supplies.

(4) Available health insurance programs, cash
or service indemnity, scope of benefits, complete-
ness of coverage, cost.

(5) Delivery mechanisms by area, private so-
lo practice, fee-for-service group practice, pre-
paid group practice, hospital practice in-hospital
and clinic, full or part-time.

(6) Morbidity and mortality statistics by area
or region.

(7) Professional education and training at the
undergraduate, graduate, and postgraduate levels.

The above list is obviously incomplete but it
does serve to indicate the range and type of in-
vestigation the academy will be required to un-
dertake and the problems with which it must be
equipped to deal.

STAFFING OF THE ACADEMY

The organization of the working echelons must
be left to the executive officer and the board of
directors to determine, but a few comments are
pertinent at this point. Earlier in this report it
was recommended that the Association encourage
and assist constituent and component medical so-
cieties to organize divisions for socio-economic
studies at their respective levels. It was suggested
that when the size of component societies did not
warrant such a department, the division be based
on a region or a district branch, rather than in-
dividual counties. The function of these divisions
would be to accumulate the information previous-
ly outlined, in a uniform manner, preferably suit-
able for central electronic data processing. The
formation of these divisions would meet the im-
mediate need of the AMA and the societies at
the state and local levels for current data and
would be worthwhile on that score alone.

If the academy’s other member professional as-
sociations could be motivated to form similar lo-
cal and state bodies in their own fields, the health
professions would have at their disposal a com-
plete data harvesting network, with horizontal
and vertical channels or coordination and com-
munication. The academy could then serve as an
apical nerve center, equipped to analyze the data
it receives, synthesize policy, and redisseminate
processed information for the benefit of its sub-
groups. The divisions would remain with their re-
spective societies at least until the academy is
well established and has proved its viability. At
that time, any duplication of function could be
eliminated by transferring individuals, or even
entire divisions, from the professional societies to
the academy, with corresponding adjustments in
financial contributions.

FUNDING OF THE ACADEMY

The funding of the academy should be the
responsibility of the participating associations.
Their initial investment should be proportionate
to their representation on the board of directors
and should not be large since, at the beginning,
the academy staff will rely on the mechanisms
established by the member organizations for data
accumulation. Some investment will be required
for data processing equipment, and assessments

APRIL 1970

245

HOUSE OF DELEGATES / Continued

of member organizations will be necessary to de-
fray continuing expenses.

The availability of federal grants for establish-
ing the academy should be investigated, but at
no time should such grants constitute a major por-
tion of the academy’s income. Once the academy
is formed and is functioning satisfactorily, it may
be allowed to undertake limited research proj-
ects on a grant or fee-for-service basis, provided
that such activities do not interfere with the ful-
fillment of its primary functions or conflict with its
basic purposes.

THE ACADEMY— PROS AND CONS

Disadvantages

( 1 ) It will be difficult and time consuming to
bring the associations representing different dis-
ciplines together in this type of cooperative ef-
fort. This is undeniable and, if the academy were
the sole thrust of the Committee’s recommenda-
tions, the entire concept would be unsatisfactory.
While the process of organizing the academy is
in process, however, the Committee would ex-
pect that, by implementing its short-term propos-
als, the AMA and the state and county medical
societies will improve their own functions suffi-
ciently to meet their interim needs.

(2) The AMA would relinquish its control
over policy making. Such loss of authority is
imaginary rather than real. To begin with, policy
formed by the academy, based on valid data,
and developed in a continuous and logical man-
ner, should almost invariably be acceptable to
the House of Delegates and the Board of Trustees.
In addition, since the AMA’s structure would re-
main intact, its control over internal policy for-
mulation would be undiminished and it would
retain the right to reject any or all of the acade-
my’s recommendations.

(3) By adopting the academy concept, the
AMA would admit to inadequacy in the field of
health care planning. It is the Committee’s opin-
ion that, far from detracting, the Association
would add to its stature by assuming the initiative
in establishing a truly competent research and
development organization among the health pro-
fessions.

Advantages

(1) The academy would bring together all or
most of the disciplines involved in the delivery
of health services and thereby make coordinated
and effective planning possible.

(2) The academy would free the framers of
policy recommendations from political repercus-
sions in their own professional associations. It will

therefore be free of the stigma of trade unionism
and its recommendations will be more acceptable
to the public than those made individually by
the member associations.

(3) The present political structure of the
AMA and all other member associations will be
preserved intact and hopefully improved. Should
the proposed academy fall short of its objectives,
there would be no disruption of continuity or
function among its sponsors.

(4) The academy would not interfere with
continuing legislative or public relations activities
by the AMA or any of the member organizations.

(5) The academy would not interfere with
continued political action by any organization of
health care professionals.

SUMMARY

It may seem visionary and impractical to ex-
pect professional organizations to unite in a ven-
ture of this sort since their past history does not
indicate a pervasive spirit of cooperation among
them. On the other hand, it is time that all pro-
fessional societies realize that they have new and
important functions to serve in an increasingly
complex environment. They will be required to
render services to their members in terms of in-
forming them of current trends, advising them on
the courses of action they should take, and rep-
resenting them in negotiations with insurance car-
riers, consumer groups, government, and a num-
ber of other agencies. To be effective in this, they
must enjoy the best possible public image, be
meticulously informed on all aspects of health
care, and have the complete support and con-
fidence of their members. The joint type of or-
ganization proposed herein will contribute to-
ward the realization of all these conditions.

The alternative to the formation of an Acad-
emy of Health Professions is the continuation of
the present and demonstrably futile endeavors of
individual associations to secure data, formulate
policy, and gain acceptance of that policy by gov-
ernment and the consumer public. There is little
reason to expect this type of activity to be more
successful in the future than it has been in the
past.

The health professions have much to contribute
to health planning that is currently being lost.
This is not only an immediate detriment to plan-
ning but, by diminishing the stature and influence
of the professional associations, it deprives the
public of their future advice and assistance. The
pooled expertise and planning capacity of the
health professions is a public asset that should
not be allowed to go to waste. The Committee
believes that the proposals contained herein will
facilitate the full development of that potential.

246

JOURNAL MSM A

MINORITY REPORT

COMMITTEE ON PLANNING
AND DEVELOPMENT

Submitted by John H. Budd, M.D.

As a member of the AMA Committee on
Planning and Development I am deeply con-
cerned with the Committee Report in its present
form. Many of the viewpoints expressed and the
recommendations advanced differ, sometimes
sharply, from my own and from what I consider
to be the sentiments of the House of Delegates.
I therefore feel impelled to make my reactions
and opinions known.

The Committee Report is extremely impor-
tant. Some of its proposals would lead, if adopted,
to far-reaching and epochal changes in the phi-
losophy, policy, responsibility, scope of activity
and commitment of AMA.

I also find a good deal of the basic tone unac-
ceptable to me, and, I expect, to the House of
Delegates, notably the air of apology and self-
denunciation which pervades some of the Re-
port.

After receiving the final edited version of the
Report, and prior to its submission to the Board
of Trustees, I sent to the Committee Chairman
an annotated critique of the document, which he
graciously acknowledged, and from which he
stated he adopted a number of my suggestions. I
also wrote to the Board of Trustees, urging that
precipitate action be avoided and that the Re-
port be returned to the Committee for recon-
sideration and revision.

In support of the latter recommendation I of-
fered a partial list of passages which I consid-
ered unacceptable to my own philosophy and
which I believe the House of Delegates should
weigh very seriously. These passages still appear
in what I understand to be the final edited ver-
sion and I am troubled.

Among the points of disagreement and the
declarations which I am disinclined to support,
and which prompt this Minority Report are the
following:

( 1) Page 4, line 40 et seq. “Further encroach-
ments (on the time honored privileges, prerog-
atives and authorities of physicians) seem in-
evitable if the public is to get the health services
it needs at a price that it is able, or willing to
pay.”

Comment: the “soaring demand for health
services” and the reasons for it, as well as the
predictions of demand outstripping capabilities,
rising costs, depersonalization of physician-patient
relationship are thoughtfully and accurately ex-

pounded; likewise the need to attract into medi-
cine the best qualified individuals in increasing
numbers. However, on page 5, line 20 et seq. I
see no need for supporting further restriction of
traditional privileges and freedom; in line 33, in-
stead of the term “minimal regimentation” I pre-
fer “maximum professional independence and
freedom of choice” for both physicians and pa-
tients. Regimentation in any degree is not an in-
centive.

(2) Page 6, line 6. The WHO definition of
health as it pertains to the field of medicine and
the responsibility of the physician is extremely
broad. It is, of course, Utopian and thus doubt-
less desirable, but “complete social well being”
which involves satisfaction in financial, political,
esthetic, climatic, transportational, recreational
and endless other areas seems to me beyond the
responsibility, expertise and limits of time and
physical capability of the medical profession.

Assuming responsibility for conditions which
appear well beyond the influence and control of
AMA is to invite more criticism of the medical
profession when their impossibility of attainment
becomes evident.

(3) Page 6, lines 43-44. I do not like the sug-
gestion that “restraints on the authority and scope
of activity of public health officials” precluded
their success and leadership in the planning and
implementation of health care programs, thus im-
plying that their authority and scope of activity
be extended (while those of physicians will, as
warned, be abridged).

A major contribution of AMA in “bringing
order to this chaotic field (page 6, line 48) would
be to encourage prudence in political promises,
careful selection of achievable priorities in health
goals, and restraint in committing taxpayers’
money.

(4) Page 7, line 51. “people will support, or
at least not oppose, the expenditure of large sums
of tax money on broad programs for social wel-
fare.”

I believe the enthusiasm for such expenditures
is cooling, and will continue to wane. Rejection
of proposed levies for school bonds, police and
fire department salary increases and similar
worthy purposes is increasingly common.

(5) Page 10, line 32. “In the past one either
paid for medical services or received them from
government.” This is neither a factual or fair
statement. The alternatives to paying for medical
services have not been limited to governmental
bounty. True, government to some extent (and
often in inadequate and penurious degree) fi-
nanced some care but much has been furnished
by the personal benevolence of physicians and

APRIL 1970

247

HOUSE OF DELEGATES / Continued

other philanthropic individuals. It should also be
remembered that government does not provide
“Medical Services”; it only exacts taxes to pay for
such care.

(6) Page 13, line 30. That the shortage of
physicians in rural communities is real and seri-
ous is agreed but I do not believe that “heavy
patient loads and poor reimbursement,” especial-
ly the latter, are substantial reasons for the short-
age in these communities and I think such refer-
ence is unjust and may offend many such prac-
titioners.

(7) Page 15, paragraph 2. This section, re-
garding manpower deficiencies is well done; the
points made are good. I suggest it should be ex-
panded to make clear the fact that the basic
shortage is in the number of physicians provid-
ing direct patient care because of the many who
are attracted into (a) research, and (b) educa-
tion (both admittedly vitally necessary, always
alluring, exalting and intellectually rewarding,
free of the obligation and inconvenience of deal-
ing directly with sick people, and now more ade-
quately reimbursed), (c) administrative medi-
cine (insurance, industry, hospital operation, etc.)
with paid vacations, sabbaticals, retirement pen-
sions, etc. and (d) the government, including of
course those appropriated by the military ser-
vices.

Much capricious, arbitrary and unfair criticism
has been directed at AMA as being responsible
for the shortage of physicians. The reasons just
recited are beyond the influence and control of
AMA and this fact should be brought to public
attention.

(8) Page 18, line 43 and in all places from
here on where “usual, customary prevailing and
reasonable” are referred to, especially where
AMA policy is concerned, the phrase should read
only “usual, customary and reasonable” even
though, by implication, the “prevailing” concept
is included over the objection of a number of
State Delegations, including Ohio’s.

(9) Page 19, line 5. I am unable to agree that
it is illogical for AMA to “call for objective ex-
perimentation in the organization of medical ser-
vices and in the same breath express its prefer-
ence for private, fee-for-service practice.” I do
not believe it inconsistent to call HEW to task for
giving preferential financial support and subsidy
to one form of medical practice and simultane-
ously express the Association’s partiality for an-
other. There is a difference, in my judgment, be-

tween providing funds (from taxpayers) to sub-
sidize one form of organization for medical prac-
tice (HEW action) and expressing a preference
(AMA action) while still advocating objective
investigation and experimentation.

(10) Page 20, paragraph 1. That other sys-
tems of practice are in some circumstances ac-
ceptable, appropriate, advisable, or even neces-
sary, is undeniable, but private practice should
not be disparaged nor its support abandoned.

I would be pleased to see the paragraph re-
stated— “in seeking as its goal the highest quality
of patient care, the most effective use and broad-
est availability of the science and art of medicine,
the Association advocates factual investigation
and objective experimentation in new methods of
delivery of health care, while still maintaining
faith and trust in the private practice of medi-
cine and pride in its accomplishments.”

(11) Page 21. line 3. “There has been an ap-
preciable increase in physicians’ incomes since
1966 while, during the same time, the medical
profession has been unable to bring about a ma-
terial expansion of its capacity to deliver health
services.”

One of the reasons for increased income is in-
deed increased productivity and output by phy-
sicians working longer hours. It is true that use
of automation, data processing, computer tech-
niques in history recording and differential diag-
nosis, etc. are only beginning and offer great pos-
sibilities; however, I consider gratuitous support
of the frequently unwarranted criticism of phy-
sicians’ incomes unnecessary and offensive.

(12) Page 23, line 3. “Medical societies have
absolutely no jurisdiction over the charges made
by their members.”

Medical societies have indeed rather severe
jurisdiction over charges made by members when
excessive. Peer review, honestly used, is a potent
instrument and grossly excessive fees may be con-
sidered unethical, and thus the offending mem-
ber may be subject to discipline by censure, sus-
pension or expulsion. Though not legal power,
this is effective if used. Furthermore, in Ohio at
least (and maybe in other states as well), viola-
tion of the ethics of a professional society by a
member can result in withdrawal of the offender’s
license by the State Board. This is legal power.

(13) Page 26, paragraphs 2, 3, 4. The mer-
its, legality, feasibility and attainable benefits of
audit of physicians’ office performance are com-
plex questions. I am well aware of the risks, and
sometimes the existence of incompetence, neg-
ligence, exploitation, over-utilization, mal-utiliza-
tion and other defects and deficiencies in the of-

248

JOURNAL MSM A

fice, and it is true that the policing procedures
usually present in the hospital are missing in the
office. Whether the proposals for office audit are
the most effective and least harmful I am not pre-
pared to say. My only plea in this complex prob-
lem is for caution and dispassionate judgment.

(14) Page 31, line 8. The distrust and fear of
government intrusion into medical practice, de-
scribed as “atavistic” is indeed well founded and
as justifiable as most primitive instincts. When
politicians’ promises become impossible to fulfill,
the medical profession is usually held to blame.
The current vilification of physicians generally for
those Medicare inequities, costs and abuses for
which the medical profession has little or no re-
sponsibility is disheartening.

(15) Page 37, line 12. I do not approve the
51 per cent consumer representation included in
PL 89-749 and I agree with the well-stated reasons
in this paragraph. However, I would delete the last
sentence in paragraph 2, page 37, line 17 be-
ginning— “Nevertheless, the intent of the law is
clear. . . Compliance with the law is proper
but offering gratuitous endorsement is unneces-
sary.

(16) Page 38 beginning at line 15. I would
prefer the following construction:

(1) Medical societies at all levels should sup-
port the concept of PL 89-749 and the
establishment of properly constituted plan-
ning agencies, provided,

(a) the areawide comprehensive health
planning agencies at local levels
have broad community representa-
tion on their boards of directors, in
contradistinction to their advisory
committees and councils. It is inad-
visable to permit local governments,
composed as they are, of elected and
appointed officials of varying capa-
bility and tenure to dominate or con-
trol health planning.

(b) that medical societies have proper
representation on the executive
bodies of the planning councils. The
societies should not accept a purely
advisory function.

(2) “To this end. . . This paragraph to be
retained as in the text.

(17) Page 42, line 2. Rather than “create the
general belief,” which sounds like promoting de-

ception, I prefer “make it clear” as a more posi-
tive and accurate statement.

(18) Page 45, lines 41-42. “The Associa-
tion’s opposition to Medicare was more emotional
than objective. . . .”

I consider this a shocking denunciation. The
accuracy and objectivity of AMA’s arguments in
opposition to Medicare are clear to me. AMA
warned of abuses, over-utilization, costs exceed-
ing estimates, misunderstandings, inequities and
failures which are now very evident. Most testi-
mony before the House of Delegates 1965 An-
nual Convention was in fact more objective than
emotional. All AMA testimony before Congres-
sional Committees was consistently objective.

(19) Page 47, line 20 et seq. I deem this an
unjust appraisal of the physicians who comprise
the House of Delegates. Having successful prac-
tices, with patients derived mostly from mid-
dle and upper income brackets (though this is
frequently not the case), being conservative in
political and social philosophies, and being con-
cerned with preserving the traditions of their
profession and their time-honored relationships
with their patients are not derogatory qualities
and I do not believe they preclude objective judg-
ment by honorable men. Criticism, to be sure, is
offensive when unwarranted, but I don’t think
most physicians are resentful of legitimate criti-
cism.

This list is partial, and represents a sampling.
My purpose is not to destroy a comprehensive
document of good intent, or to malign a commit-
tee on which it was a privilege to serve. My
criticisms are intended to be constructive.

There is merit in much of the Report’s com-
mentary, and in many of its analyses and recom-
mendations. To point out just a few, the depic-
tion of the present social and political climate,
(page 9, line 1), exposition of the varying non-
medical reasons for poor health of the under-
privileged (page 11, line 38), and evaluation of
delivery systems of health care, including closed
panel groups, are perceptive, relevant and ac-
curate.

The document deserves fair hearing and calm
judgment. In my opinion it needs modification;
precipitate action should be avoided.

I hope that my dissenting opinions will be
given serious consideration, my suggested changes
adopted, and my motives understood.

APRIL 1970

249

HOUSE OF DELEGATES / Continued

RESOLUTION NO. 2, AMENDMENT OF
ABORTION LAWS, BY J. PURVES
MCLAURIN, DELEGATE FROM THE
SCIENTIFIC ASSEMBLY (OB-GYN)

Whereas, Mississippi law prohibits abortion
except where continuation of the pregnancy poses
a threat to the life of the patient or where the
pregnancy results from forcible or statutory rape,
and

Whereas, A significant number of states have
recognized that abortion may be lawfully per-
formed when one of the foregoing conditions
prevails or when the pregnancy results from in-
cest, when continuation of the pregnancy poses a
threat to the health of the patient, and/or when,
in cognizant medical opinion, there is a probabil-
ity that the infant will be born deformed, and

Whereas, The American Medical Association
and the American College of Obstetricians and
Gynecologists have respectively approved abor-
tion under any one of the foregoing conditions,
and

Whereas, There is strong opinion among citi-

zens of the state and the medical profession that
the Mississippi law should be amended to re-
flect these additional socially and medically ac-
ceptable conditions under which this procedure
may be performed, now, therefore, be it

Resolved, That the policy of the Mississippi
State Medical Association be that abortion should
not be performed except when (1) the preg-
nancy results from forcible or statutory rape or
from incest, (2) continuation of the pregnancy
poses a threat to the life or health of the patient,
or (3) when, in cognizant medical opinion, there
is a probability that the infant will be born de-
formed and that the procedure be undertaken
by a physician only (1) when consultation has
been obtained in writing from another physician
and (2) the procedure is performed in a licensed
hospital, and be it further

Resolved, That this policy in no way alters
the association’s long-standing view that criminal
or illicit abortion be vigorously prosecuted under
applicable criminal law, and be it further

Resolved, That amendments in existing Mis-
sissippi law be sought to implement this policy
during the 1971 Regular Session of the Mississip-
pi Legislature.

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250

JOURNAL MSMA

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Index to Advertisers

Arch Laboratories 251

Breon Laboratories 8

Bristol Labs 12

Burroughs Wellcome 23 6B

Campbell Soup Company 192A

Dow Chemical Company 14A

Lakeland Nursing Center 14

Lederle Laboratories 4, 250

Eli Lilly front cover, 18

William S. Merrell 15

Mid-South Medical Association 162

National Drug Company second cover, 220A, 220B

Wm. Poythress 23 6C

Geigy 236A, 236D, 237

Glenbrook Laboratories 233

Highland Hospital 6

Hillcrest Hospital 11

Hoechst Pharmaceuticals 243

Hynson, Westcott and Dunning 3

A. H. Robins 14B, 192D, 204A, 204B, 239

Roche Laboratories 7, 159, fourth cover

Julius Schmid 16, 17

Searle 192B, 192C

Smith, Kline and French 10

Kay Surgical

251 Thomas Yates and Company

third cover

APRIL 1970

251

A state-wide peer review system is being organized by the Illinois
State Medical Society and will be operational in June. Plan calls
for searching review of care, including physicians' services and
private and governmental care programs. Objectives are conserva-
tion of patients' health dollar, proper use of M.D. 's and hospi-
tals, and high standards of practice. State government and major
insurance carriers have agreed to abide by society's decisions.

Small cars are the killers , says the University of North Carolina
in study report of 270,000 auto accidents. Worst record was made
b£_ the Volkswagen bus, followed by Volkswagen sedans, Chevy llf
Corvair, Plymouth Valiant, small Dodge, and Ford Fairlane. Study
also showed that American Motors Hornet is costliest car to fix
after low speed crash and 1970 Volkswagen is cheapest.

First multiphasic screening services for children under Mississippi
Medicaid was initiated in Vicksburg. Pilot program was carried oul
by State Board of Health which will be paid by Medicaid. An esti-
mated l,ti00 Warren County children on welfare were eligible for
exams to find heart, vision, and hearing defects, tuberculosis,
anemia, and congenital anomalies. Children with problems are refei
red to private physicians or to county health department.

United Medical Laboratories of Portland, Ore., has filed suit for
$24 million and injunctive relief against discriminatory practices
by medical organization. Named as defendants were AMA, College of
American Pathologists, California tae&ical Association and its com-
ponent medical societies, and California Blue Shield. UML asks
court to rule that M.D. -clients may mark up lab charges to patients

Joint Commission on Accreditation of Hospitals will accredit ap-
proved institutions for only two years instead of former three.
Accreditation may be for only one year when JCAH finds that re-
quired improvements have not been made. Fees for surveys are high-
er with prime surveyor (M.D.) costing $240 per day and $150 per daj
for other survey team members. ECF survey fees are $220 per day*

Volume XI
Number 5
May 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL CONSULTANT
Betty M. Sadler

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
James L. Royals, M.D.

President

Paul B. Brumby, M.D.

President-elect
Walter H. Simmons, M.D.

Secretary-Treasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

original papers

The Management of Early
Invasive Carcinoma of the
Cervix: Surgery or

Irradiation? 253 Bernard T. Hickman,
M.D., and John Y.
Gibson, M.D.

New Dimensions in
Emergency Medical

Rescue Services 257 B. J. Shell, Ph.D.,

J. E. Clark, Ph.D., and
P. Y. Nicholas

SPECIAL ARTICLES

Clinicopathological

Conference XCVI 262 Alvin E. Brent, Jr.,

M.D., and Louis
Schiesari, M.D.

Radiologic Seminar XCV

Multiple Myeloma 268 June G. Blount, M.D.

EDITORIALS

The Family Practice
Specialist: Medicine’s
New Man
Part 1-B Is a
Two-way Street
The Nelson Syndrome and
Pill Complications
Medical Corpsmen,
New Manpower Pool

The Cost Dilemma
of Hospital Services

THIS

The President Speaking
Medical Organization

273 Key to Delivery?

275 Distress and Protest

276 Insidious Doubt

276 Salvaged Health Careers

277 Up, Up, and Away!

MONTH

272 Past and Future:

The Task Ahead

283 Building Addition
Open House

Copyright 1970. Mississippi State Medical Association

6

THE JOURNAL FOR MAY 1970

Southern Ob-Gyn Seminar

Set for July

The 16th annual Southern Obstetric and Gyne-
cologic Seminar is scheduled for July 27-31 at
Grove Park Inn in Asheville, N. C.

A wide variety of obstetric and gynecologic
subjects will be covered including cryosurgery,
vaginal surgery, cervical dysplasia and carci-
noma, obstetrical anesthesia, infertility and hor-
monal and pituitary ovarian balance studies.

Faculty for the seminar includes Dr. Bayard
Carter of Duke University, Dr. Robert Barter
of Washington, Dr. Raymond Kaufman and Dr.
Robert Franklin of Baylor University, Dr. Rob-
ert Greenblatt of Georgia, Dr. Duane Townsend
of California, and Dr. Charles Hendricks of the
University of North Carolina.

Registration is limited to the first fifty appli-
cants. For information and registration contact
Dr. George T. Schneider, Ochsner Clinic, 1514
Jefferson Highway, New Orleans, Louisiana
70121.

Dr. P. C. Zamecnik
Receives Passano Award

The Passano Foundation announced the se-
lection of Dr. Paul C. Zamecnik to receive the
$7,500 Passano Award for 1970, one of the
highest awards in American medicine.

The Passano Foundation is a Maryland non-
profit corporation with the sole purpose of en-
couraging medical science and research, espe-
cially that having a clinical application. Of the
30 Passano laureates sharing in the award since
1945, six have subsequently received the Nobel
Prize.

Dr. Zamecnik, 57, is professor of oncologic
medicine at the Harvard University Medical
School and director of J. Collins Warren Labora-
tories of Huntington Memorial Hospital at Mas-
sachusetts General Hospital in Boston.

His research, on which the award is based,
centers on the chemical processes in both normal
and tumor cancer cells, particularly the incorpo-
ration of amino acids into proteins — the building
of proteins by body cells.

HOSPITAL

( Formerly Hill Crest Sanitarium j

7000 5TH AVENUE SOUTH
Box 2896, Wood lawn Station
Birmingham, Alabama 35212

Phone: 205-836-720!

A patient centered
independent hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 44 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James A. Becton, M.D., F.A.P.A.

CLINICAL DIRECTORS:

James K. Ward, M.D., F.A.P.A.
Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL;

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

SMC Os t

HOSPITAL

BIRMINGHAM, ALABAMA

May 1970

3 c Doctor:

is pressing for equal time to rebut slanted, editorializing CBS
a svision series making pitch for compulsory health insurance. The
7 hour-long documentaries attacked delivery system and care costs,
ist program, "The Promise and the Practice," underscored out-of-
: text examples to allege unavailability of medical services, long
■ ts by patients, and difficulty of getting into a hospital.

Second segment, "Don't Pet Sick in America," used far-
fetched examples on bankruptcy in illness. One was
dialysis case and other was private patient with no in-
surance coverage which seven out of eight Americans have.

AMA seeks hour in prime time to give facts and figures.

cutive session vote in powerful House Ways and Means Committee
ures that effort to get chiropractic into Medicare has failed.
Assures were brought on Congressmen from states licensing cul-fcis ts
put chiropractic in Part 1-B, and more than 100 Representatives
liked such bills. Word is out that committee is also about to de-
it HEW proposed Part C which would put closed-panel or prepaid
act ice options in Medicare.

iliminary hearings have been held on $24 million lawsuit by United
lical laboratories against medical organization and Blue Shield,
aplaint against AMA, California Medical Association, College of
Brican Pathologists, and others seeks treble damages and injunction
Leging antitrust practices in clinical laboratory field. Plaintiff
so seeks setting aside 1969 CRVI codes on certain lab procedures.

3 nationts biggest state medical society. New York, has endorsed
program of national health insurance"! Program would be tailored
Dng lines of Medicare, utilizing co-insurance but no deductibles.

3 of private carriers is urged, and plan calls for financial parti-
pation by employers and states. There is similarity between N.Y.
Dgram and that proposed by state's Gov. Nelson Rockefeller.

srican Academy of General Practice has endorsed AMA's Medi credit
an for voluntary, tax-credit health coverage. Action was announced
AAGP Board Chairman Robert Quello who said that "we believe an
septable alternative is provided by insurance through tax credits."
support is expected to give proposal new impetus.

Syntfirnid

(sodium levothyroxine)

1 o

Educational Cassettes
Developed for Nurses

A new nursing service education program
using audio-tape cassettes has been announced
by the National League for Nursing, New York.
Designed for inservice education of nurses, nurse
administrators and other health professionals,
the NLN Nursing Service Cassettes features lec-
tures and discussions packaged in 60-minute cas-
settes suitable for group or individual use.

Two initial NLN nursing service cassette se-
ries are devoted to staff development and the
nursing audit. These were adapted from NLN’s
1969-70 hospital nursing service continuing edu-
cation workshops. The League has produced these
cassettes to meet the needs of hospitals, nursing
homes, extended care facilities, public health agen-
cies, and schools of nursing to study nursing top-
ics of current interest with nursing authorities.

The staff development cassette series has been
recorded by Myrtle Kitchell Aydelotte, Ph D., di-
rector of nursing services. University of Iowa Hos-
pitals, Iowa City. This series is intended to help
nurse administrators stretch their professional de-
velopment, and suggest ways nursing depart-
ments can improve staff development programs
or create new programs where the need exists.
The series of four cassettes highlights the factors
affecting performance of nurses, behavior pat-
terns of personnel, case histories, and evalua-
tion of staff development program. The cost is
$25.00.

The nursing audit cassette series by Helen W.
Dunn, director of nursing. University of Illinois
Research and Educational Hospitals, Chicago,
is designed to help health service institutions
improve techniques of evaluating nursing care
through effective management of the nursing
record, and to develop skills in auditing meth-
ods. This series is on two cassettes accompanied
by a Nursing Audit Workbook which includes
documents and forms for supplementary listener
instruction. The cost, including the Workbook, is
$20.00.

Instructions for use of the cassettes in inser-
vice education seminars, group listening, by in-
dividuals, and as a library resource are included
with each series.

The NLN Nursing Service Cassettes have been
produced in collaboration with Instructional Dy-
namics, Inc., Chicago, leaders in the field of
audio-education techniques. Easily played on por-
table playback units, the cassettes offer versatility
and low cost for institutions and individuals in-
terested in keeping abreast of recent thought and
developments in health care.

Indications : SYNTHROID (sodium levothyroxine) is specific re|
ment therapy for diminished or absent thyroid function res1''
from primary or secondary atrophy of the gland, congenital d
surgery, excessive radiation, or antithyroid drugs. Indication
SYNTHROID (sodium levothyroxine) Tablets include myxei,
hypothyroidism without myxedema, hypothyroidism in pregr
pediatric and geriatric hypothyroidism, hypopituitary hypoth1
ism, simple (non-toxic) goiter, and reproductive disorders assoc
with hypothyroidism. SYNTHROID (sodium levothyroxine) lnj(
is indicated in myxedematous coma and other thyroid dysfum
where rapid replacement of the hormone is required. When
tient does not respond to oral therapy, SYNTHROID (sodium;
thyroxine) injection may be administered intravenously to avoi
question of poor absorption by either the oral or the intramu;
route.

Precautions: As with other thyroid preparations, an overdi
may cause diarrhea or cramps, nervousness, tremors, tachyci
vomiting and continued weight loss. These effects may begin'
four or five days or may not become apparent for one to three \a i
Patients receiving the drug should be observed closely for sic
thyrotoxicosis. If indications of overdosage appear, discor,
medication for 2-6 days, then resume at a lower dosage lev-
patients with diabetes mellitus, careful observations should be jj
for changes in insulin or other antidiabetic drug dosage ret"
ments. If hypothyroidism is accompanied by adrenal insufficien
Addison's Disease (chronic subcortical insufficiency), Simmo;
Disease (panhypopituitarism) or Cushing’s syndrome (hypera,
alism), these dysfunctions must be corrected prior to and d"
SYNTHROID (sodium levothyroxine) administration. The!
should be administered with caution to patients with cardiovasj
disease: development of chest pains or other aggravations o
diovascular disease requires a reduction in dosage.

Contraindications: Thyrotoxicosis, acute myocardial infarctioi

Side effects: The effects of SYNTHROID (sodium levothyrc
therapy are slow in being manifested. Side effects, when th '
occur, are secondary to increased rates of body metabolism: si
ing, heart palpitations with or without pain, leg cramps, and v\
loss. Diarrhea, vomiting, and nervousness have also been obsq
Myxedematous patients with heart disease have died from a1
increases in dosage of thyroid drugs. Careful observation c
patient during the beginning of any thyroid therapy will ale
physician to any untoward effects.

In most cases with side effects, a reduction in dosage follow:
a more gradual adjustment upward will result in a more acc,
indication of the patient's dosage requirements without the ap1
ance of side effects.

Dosage and Administration: The activity of a 0.1 mg. SYNTH
(sodium levothyroxine) TABLET is equivalent to approximate!!
grain thyroid, U.S.P. Administer SYNTHROID tablets as a i\
daily dose, preferably after breakfast. In hypothyroidism wi1
myxedema, the usual initial adult dose is 0.1 mg. daily, and m
increased by 0.1 mg. every 30 days until proper metabolic balai
attained. Clinical evaluation should be made monthly anc
measurements about every 90 days. Final maintenance dosag
usually range from 0.2-0. 4 mg. daily. In adult myxedema, stz
dose should be 0.025 mg. daily. The dose may be increased t
mg. after two weeks and to 0.1 mg. at the end of a second two v\
The daily dose may be further increased at two-month intervz
0.1 mg. until the optimum maintenance dose is reached (0.1-1.
daily).

Supplied: Tablets: 0.025 mg., 0.05 mg., 0.1 mg., 0.15 mg., 0.2 m
mg., 0.5 mg., scored and color-coded, in bottles of 100 and 500.
tion: 500 meg. lyophilized active ingredient and 10 mg. of Mar
N.F., in 10 ml. single-dose vial, with 5 ml. vial of Sodium Ch
Injection, U.S.P., as a diluent.

SYNTHROID (sodium levothyroxine) INJECTION may be adr
tered intravenously utilizing 200-400 meg. of a solution conta
100 meg. per ml. If significant improvement is not shown the f<
ing day, a repeat injection of 100-200 meg. may be given.

FLINT LABORATORIES

DIVISION OF TRAVENOL LABORATORIES. INC.

Morton Grove, Illinois 60053

3x Data Makes Jackson - "Medex Data,” or M.D. , a new billing
at Biloxi and practice management service for Mississippi

physicians will debut at the 102nd Annual Ses-
n with a special exhibit. Presentation seeks determination of
. interest in low-cost computer billing, receivables analysis,
ctice analysis, and other reports. Medex Data is wholly owned
Mississippi State Medical Association and will cost less than
mercial services. Phase-in will be on first-come, first-served
is over next 12 months.

t Taste Good Kalamazoo, Mich. - An Upjohn research scientist,

e an Rx Should Louis Schroeter, has published a new book, "In-

gredient X," with fascinating disclosures about
ional preferences in medicines and problems of drug-making. Ger-
s, Italians, South Americans, and some Asians want orange-flavored
icines, but Norwegians prefer anise. Americans have no particular
ference, but cherry-flavored liquids remain in good demand. He
s flavor is just one of many acceptability problems in drugs.

w Acceptance Is Chicago - AMA has published the second edition
dieted for CPT of "Current Procedural Terminology" designed to

assist in preparing claims for medical services
h insurance and government programs. But acceptance is likely to
slow, because five-digit codes will not initially replace current
r-digit designations used by Blue plans, CHAMPUS, Medicare, and
ers. Estimates are that conversion costs to fiscal administrators
Id be substantial and out of proportion to benefits.

h Court Nominee St. Louis - New Supreme Court nominee Harry A.

Mayo Lawyer Blackmun, current member of the 8th Circuit

Court of Appeals, is no stranger to medicolegal
ters. The native of Rochester, Minn. , once served for eight years
private practice as legal counsel to the Mayo Clinic. Judge
ckmun has published papers and studies on medicolegal matters, and
is considered expert in the field.

lup Poll Says Raritan, N.J. - A special Gallup Poll made for
1 Is Coming Back Ortho shows that The Pill is coming back. Hear-
ings conducted in Congress gave Pill setback, but
poll says that just 13 per cent of women have gone off oral con-
ceptives, while 69 per cent said they would continue to take them,
ut 17 per cent of the "dropouts" have gone back, and other 26 per
t are undecided about returning.

THE JOURNAL FOR MAY 1970

1 4

Charles Caffey
Field Representative —
Northern Mississippi
1 1 1 Lilac Drive
Leland, Mississippi
Phone: 686-4753

Warren Edwards

Field Representative —
Central Mississippi
530 E. Woodrow Wilson
Jackson, Mississippi
Phone: 366-1422, Ext. 42

These

Blue Shield

men are just a

phone call away

Contact them and they’ll . . .

□ Render assistance to you or to your medical assistant
or bookkeeper.

□ Assist in training your new personnel in the use of claims
forms.

□ Interpret Blue Shield contracts so there will be complete
understanding regarding coverage and payment.

□ Discuss any new benefit areas into which Blue Shield
may be moving.

□ Help with unusual cases, especially when there is an
unforeseen delay for various reasons.

Max Gilliland
Field Representative —
Southern Mississippi
620 South 28th Avenue #422
Flattiesburg, Mississippi
Phone: 582-0479

□ Check your Blue Shield physician’s manual to make sure
that it is current.

□ Serve as a liaison between you and the Blue Shield Plan.

BLUEftCROSS.

BfUFffSHIFl D

Mississippi Hospital and Medical Service
P. O. Box 1043 / Jackson, Mississippi 39205

Symptoms subside
in 48 to 72 hours!

Itching, burning, discharge,
and malodor disappear rapidly...
patient's embarrassment, too.

Avoids the
disappointment
of “the cure

that didn’t take.”

Candeptin is“cidal"as well as“static,"
it is 100 times more potent in vitro
than nystatin,2 and it has achieved
culture-confirmed cure rates of
90% and more3 (even in notoriously
d iff icu It-to-treat pregnant patients)?'3-4

And two weeks does it.

Usually, Candeptin cures in
a single 14-day course of therapy.3

the fortnight fungicide

Candeptin

candicidin

Vaginal Tablets/Ointment

Formula: CANDEPTIN Vaginal Ointment con-
tains a dispersion of candicidin powder equiva-
lent to 0 6 mg. per gm. or 0.06% candicidin activity
in U.S.P. petrolatum. 3 mg. of candicidin is con-
tained in 5 gm. of ointment or one applicatorful.
CANDEPTIN Vaginal Tablets contain candicidin
powder equivalent to 3 mg. (0.3%) candicidin ac-
tivity dispersed in starch, lactose and magnesium
stearate.

Indications: Vaginal moniliasis due to Candida
albicans and other Candida species.

Contraindications: Patient sensitivity to any
of the components. During pregnancy manual
tablet insertion may be preferred since the use of
the ointment applicator or tablet inserter may be
contraindicated.

Caution: Clinical reports of sensitization or tem-
porary irritation with CANDEPTIN Vaginal Oint-
ment or Vaginal Tablets have been extremely
rare. To avoid reinfection, it is recommended that
the patient refrain from sexual intercourse during
treatment or the husband wear a condom.
Dosage: One vaginal applicatorful of CAN-
DEPTIN Ointment or one Vaginal Tablet is
inserted high in the vagina, twice a day, in the
morning and at bedtime, for 14 days. Treatment
may be repeated if symptoms persist or reappear.
Dosage forms: CANDEPTIN Vaginal Ointment
is supplied in 75 gm. tubes with applicator (14-
day regimen requires 2 tubes). CANDEPTIN Vag-
inal Tablets are packaged in boxes of 28, in foil,
with inserter— enough for a full course of treat-
ment. Store under refrigeration.

Federal law prohibits dispensing without pre-
scription. CANDEPTIN is a registered trade-mark
of Julius Schmid, Inc.

References: 1. Olsen, J. R.: Journal-Lancet
85:287 (July) 1965. 2. Lechevalier, H : Antibiotics
Annual 1959-1960, New York, Antibiotica, Inc.,
1960, pp. 614-618 3. Giorlando, S. W„ Torres, J. F„
and Muscillo, G Am. J. Obst. & Gynec. 90 370
(Oct. 1) 1964 4. Friedel, H. J.: Maryland M. J.
75 36 (Feb.) 1966.

Julius Schmid Pharmaceuticals
423 West 55th Street
New York, N.Y. 10019

SKF Announces
New Drug

Smith Kline & French Laboratories have an-
nounced that a new prescription drug for control
of the manic episodes of manic-depressive psy-
chosis is now available to physicians.

It is called “Eskalith,” SK&F’s brand of lith-
ium carbonate.

Use of lithium in manic-depressive psychosis
has been studied in the United States and many
other countries. The results of these studies have
been reported in numerous published papers
and have shown that lithium produced clinical
improvement in a large percentage of the manic
patients treated.

Manic episodes in manic-depressive psychosis,
one of the most difficult treatment problems fac-
ing the psychiatrist, has not responded satisfac-
torily to conventional psychopharmaceuticals.
Certain anti-depressants have been valuable in
managing depressive episodes, and electroshock
treatments sometimes provide temporary remis-
sion. However, tranquilizers with calming action
have been only partially successful in treating
manic episodes.

“Eskalith,” however, when given to a patient
experiencing a manic episode, calms the patient
and controls acute symptoms, usually within a
matter of days. “Eskalith” is not recommended
for use in depressive episodes.

Toxicity may develop with lithium carbonate
at doses near therapeutic levels. For this reason,
patients on lithium carbonate must be maintained
under close clinical supervision. Blood levels
should be monitored regularly, especially during
the initial stabilization period.

It is essential for the patient to maintain a
normal diet, including salt, and an adequate
fluid intake. Early symptoms of lithium toxicity
— such as diarrhea, vomiting, drowsiness, muscu-
lar weakness, lack of coordination — mean the
patient should stop the drug and contact his
physician. Such symptoms can usually be treated
by reducing dosage or stopping the drug and re-
suming it at a lower dosage 24 hours later. Other
adverse effects can include confusion, dizziness,
restlessness, rash, and transient visual disturbance.

The drug is contraindicated in patients with
significant cardiovascular or renal disease, or evi-
dence of brain damage.

Information regarding the safety and effec-
tiveness of the drug in children under 12 is not
available and its use in them is not recommended
at this time.

1 8

THE JOURNAL FOR MAY 1970

Additional information available upon request • Eli Lilly and Company, Indianapolis, Indiana 46206

Now

available for your
prescribing
eds

Cordrarf Tape

Flurandrenolidelape (4 meg. per sq. cm.)

000108

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

May 1970, Vol. XI, No. 5

The Management of Early Invasive

Carcinoma of the Cervix:
Surgery or Irradiation?

BERNARD T. HICKMAN, M.D., and JOHN Y. GIBSON, M.D.

Jackson, Mississippi

The correct management of cervical carci-
noma is a controversial subject at best, and dis-
cussions have been known to become heated.
All physicians want to do the best thing for their
patients; the problem is finding out what is the
best thing to do. As has often been said, “one can
prove (or disprove) anything with statistics.”
For this reason, it is fallacious to compare the
statistics from one institution treating a certain
type cancer by one form of therapy with those of
a different institution treating the same type can-
cer by some other modality. Also, the ability of
the operator must certainly be considered. The
statistics from M. D. Anderson Hospital would
certainly be expected to be more valid and su-
perior to those from Smalltown Hospital.

With this in mind, it was decided to compare
two separate methods of therapy for early in-
vasive carcinoma of the cervix in one institu-
tion.1 This involved several problems in order to
be as unbiased as possible. One person had to su-
pervise all of the surgery, and one person had to
supervise all of the radiotherapy. As uniform as
practicable selection for surgery patients and as

From the Department of Radiology, University of Mis-
sissippi School of Medicine.

uniform as possible radiation dose and method
of dose delivery for radiotherapy patients had to
be maintained. All patients had to be jointly

A comparison is made of the surgical
versus radiotherapy management of 129
cases of early invasive cervical carcinoma
treated at the University Medical Center.
Cure rates are similar but complications dif-
fer.

staged by the two supervisors, and the stage of
the lesion agreed upon. Then a random card se-
lection of patients had to be made so that satis-
factory and difficult cases would be randomly
distributed.

There were a total of 129 patients with In-
ternational Stage I carcinoma of the cervix treat-
ed at University Medical Center between Septem-
ber 1958 and September 1965. Sixty-six were
treated with irradiation and 63 were treated sur-
gically. All of the patients have been followed for

MAY 1970

253

CARCINOMA / Hickman et al

over three years but only 99 have been followed
over 5 years; 49 of these being treated surgically
and 50 receiving radiation therapy.

None but Stage I cases were included in this
random study. This staging refers to those le-
sions which are frankly invasive but which are
limited to the cervix itself with no extension into
the parametrium or onto the vagina. The stage

0 or carcinoma-in-situ type of cases were not in- i
eluded in this series. Those patients were gen-
erally treated with conization or simple hyster-
ectomy depending upon the patient’s age and de-
sire for a family. The clinical Stage II and III
cases and most of the clinical Stage IV (or far
advanced) cases were treated solely by irradia-
tion therapy. Those patients that presented with
recurrent carcinoma after therapy were individ-
ualized as to the type of therapy which was best

/SOSOSf CMnS

ANTERIOR

2ci iat from cintet U cirvii

5c* out (rani cantar af canrii T?-

^ = car vii

Figure 1. This diagramatically illustrates the The central black dot represents the cervix, the

dosage distribution through a cross-section of a paracervical area is represented by point A and
patient’s pelvis from opposing anterior and the parametrial area is represented by point B.

posterior split ports from Cobalt-60 teletherapy.

254

JOURNAL MSMA

Figure 2. The Ernst radium applicator is seen
in place at the cervix. The darkened rectangular
ports represent the area treated with the external
Cobalt-60 beam. The pelvic lymph node chains

are superimposed and it is seen that they are treated
mainly with external irradiation while the cervix
is treated mainly with radium.

suited to their particular case. In general, those
patients that had been treated with irradiation
were considered for surgical management and
those that had been previously treated surgically
were considered for radiotherapy.

The type of surgical therapy offered was a
modification of the Wertheim procedure which
consisted of a radical hysterectomy with removal
of a generous portion of the vaginal cuff and a
dissection of the pelvic lymph nodes.

The radiation therapy was administered with
two modalities. Using Cobalt 60 teletherapy, ra-
diation was delivered through opposing split an-
terior and posterior pelvic ports measuring 14 x
6 cm. until a parametrial dose of 3500r was
given. This delivered approximately 3200r to the
paracervical area. (See Figure 1.)

This was immediately followed by the single
insertion of intrauterine and intravaginal radium
in the form of an Ernst applicator. (See Figure

2.) Usually 80 mg. of radium was left in for 72
hours, delivering a paracervical radium dose of
4520r. This contributed an additional dose of
1600r to the pelvic wall for a combined para-
metrial dose of 5100r. The total combined thera-
py was administered in 40 days.

Only the severe complications are considered.
Nearly all of the patients treated surgically had
granulomatous scarring of the shortened vaginal
apex and most of the patients treated with ir-
radiation had vaginal narrowing and scarring.
Of the 66 patients treated with irradiation, 3 had
fistulae and 5 had severe proctitis (considered
severe complications). (See Table 1.) Of the 63
patients treated surgically, 31 had severe com-
plications (renal nonfunction, hydronephrosis or
bladder atony) while there were 8 fistulas. (See
Table 2.) Where the patients had more than one
complication, they are counted in each cate-
gory. All of the patients are included in this

MAY 1970

255

CARCINOMA / Hickman et al

TABLE 1

SEVERE COMPLICATIONS SEEN IN PATIENTS
TREATED WITH RADIOTHERAPY
(66 Patients)

I. Fistulae

Rectovaginal 2

Rectovaginal & uretero vaginal 1

Total 3

II. Severe diarrhea without proctitis 1

III. Radiation Proctitis 5

IV. Cystitis 3

V. Severe vaginal radiation reaction 1

group. Although 30 of them have been followed
only 3 years, we feel that most of the complica-
tions will have occurred within that interval.

Of the 50 patients that were treated with ir-
radiation that have been followed for more than
5 years, 35 are living with no evidence of dis-
ease. Of the 49 patients that were treated sur-
gically, more than five years ago, 31 are living

TABLE 2

SEVERE COMPLICATIONS SEEN IN PATIENTS
TREATED SURGICALLY
(63 Patients)

I. Fistulae

Vesicovaginal 4

Ureterovaginal 3

Urethrovaginal 1

Total 8

II. Urinary Tract complications:

Nonfunction of kidney not due to tumor . 4

Hydronephrosis and/or hydroureter 10

Infection 30

Bladder atony 18

Incontinence 10

(These complications occurred in 47 patients)

III. Surgical damage to bladder, ureter or bowel . . . 8

IV. Excessive operative blood loss (more than 1000

cc) and/or shock 11

V. Pelvic hematoma 6

VI. Miscellaneous (includes incisional hernia, wound

dehiscence, pulmonary emboli, post op atelec-
tasis, etc.) 10

Note: Where patients have more than one complica-
tion, they are counted in each category.

with no evidence of disease. These figures, how- 1 II. III. IV. V. VI.
ever, do not reflect the effectiveness of therapy.
Fourteen patients have either been lost to follow-
up or died of unknown causes, and in an overall
group of this limited size, such a segment can al-
ter statistics drastically. A truer picture might be
obtained if this group is eliminated, and only the
results obtained in the groups with adequate fol-
low-ups are analyzed. As can be seen from Table
3, the numbers of patients living with disease,
and the number who died without evidence of
cancer and those who died with evidence of can-

TABLE 3

FIVE YEAR SURVIVAL RESULTS OF PATIENTS
TREATED SURGICALLY AND
WITH RADIOTHERAPY
(99 Patients)

Radiation Surgery
rx rx

Died with evidence of disease 5 4

Died without evidence of disease 3 3

Died of unknown causes 3 0

Living with evidence of recurrence ... 2 2

Lost to follow-up 2 9

Total dead or lost to follow-up 13 16

cer are almost identical in both the radiation
treated group and the surgically treated group.
It is felt that this reflects an actual five-year sur-
vival rate of approximately 85-90 per cent for
both groups of patients.

Although the number of patients in this study
is small and doesn’t lend itself to statistical ac-
curacy, several things have been learned. This is
a random study done in a single institution and
supervised by the same investigators throughout.
The size of the two groups of patients is almost
identical and the survival rates are almost iden-
tical. The one striking difference in the two
groups is the complication rate. The complication
rate in the surgically treated group is nearly four
times as great as in the group receiving irradia-
tion. This in itself may make one select irradia-
tion therapy as the treatment modality of choice.

★★★

2500 N. State St. (39216)

REFERENCE

1. Newton, M.; Hickman, B. T.; and Bolten, K. A.:
Carcinoma of the Cervix: Treatment and follow-up,
JMSMA 2:279 (June) 1961.

256

JOURNAL MSMA

New Dimensions in Emergency
Medical Rescue Services

B. J. SHELL, Ph.D.; J. E. CLARK, Ph.D.; and P. Y. NICHOLAS

State College, Mississippi

Thirty-eight Mississippi counties are now cov-
ered by the life-saving network of the Coordinat-
ed Accident Rescue Endeavor-State of Mississip-
pi (Project CARE-SOM). This project utilizes
three helicopters that are manned by trained at-
tendants and pilots working in conjunction with
ground ambulances, and it employs the latest in
communications advancements. Funded by the
National Bureau of Highway Safety, Project
CARE-SOM is directed by Mississippi State Uni-
versity.

The overall purpose of any emergency medi-
cal care system is to save lives and reduce the
probability of disabling injuries. The elements in-
volved are transportation, communications, and
treatment. To date, attempts to improve emer-
cency medical care systems have been directed
toward the elements rather than toward improve-
ments to the total system.

The great loss of life, the widespread injury,
and the total economic loss to the nation make
highway crashes a pressing national problem.
Highway crashes are the most common cause for
death in the age group of 15 to 35 years and are
among the first three causes of death of all age
groups from the first year of life to middle age.

Project CARE-SOM focuses upon the post-
crash scene since, in spite of the efforts to pre-

B. J. Shell, Ph.D., P.E., Acting Vice-President for Re-
search at Mississippi State University, is project direc-
tor of CARE-SOM; J. E. Clark, Ph.D., P.E., Assistant
Professor of Civil Engineering at the University, is
principal investigator, and Patricia Y. Nicholas is
Editor for the Engineering and Industrial Research
Station at the University.

vent them, crashes still occur in ever-increasing
numbers. The National Research Council states
that many accident victims die needlessly be-
cause most ambulances in the United States lack

Utilizing three helicopters, Project CARE-
SOM (Cooordinated Accident Rescue En-
deavor-State of Mississippi) now covers 38
counties. The authors discuss the operation
and results of the project, which is funded
by the National Bureau of Highway Safety,
U. S. Department of Transportation and
operated by the Engineering and Industrial
Research Station of Mississippi State Uni-
versity.

the equipment, supplies, and trained attendants
for quick, adequate emergency care to the criti-
cally injured. The council says that one-third of
the more than 53,000 traffic deaths a year oc-
cur at the scene, in the ambulance, or within
minutes after arrival at a hospital. Safety ex-
perts estimate that if the same speed of evacua-
tion in Vietnam were adapted to highway or
other accidents in the United States, it could
mean a 20 per cent reduction in deaths.

Several doctors who work in emergency rooms
were recently asked, “If you could request one
change in the present system of receiving accident
victims, what would you request?” Their unani-
mous reply was that they would like to be in-

MAY 1970

257

EMERGENCY SERVICE / Shell et al

formed that casualties were coming in and the na-
ture of their injuries. Project CARE-SOM pro-
vides this vital communication link. Communica-
tion between the hospital and ambulance, as well
as properly and adequately trained attendants,
must be a part of any emergency medical care
system.

A letter dated January 29, 1970, received at
the CARE-SOM office is representative of many
received since the beginning of this demonstration
project. The letter expresses the happy thankful-
ness of a teen-age boy’s parents at his full re-
covery. The son had been in an automobile ac-
cident and was taken to a small central Missis-
sippi hospital for observation of head injuries.
In a short time, he became delirious and went
into a coma. He was immediately sent to the
University Medical Center by helicopter. His rapid
transfer to the Medical Center where he re-
ceived immediate treatment is credited with his
recovery with no permanent brain damage.

The inter-hospital transfer is only one phase of

Project CARE-SOM covers in the Emergency Med-
ical Rescue Service.

Project CARE-SOM. The vital role of the heli-
copter is to provide the most rapid aid possible
— whether it be from the accident scene to the
receiving hospital or from one hospital to another.
Project CARE-SOM is seeking to determine the
extent to which helicopter ambulance service can
be coordinated with existing ground ambulance
service in rural areas to provide a more com-
prehensive and effective emergency rescue and
treatment capability.

TABLE 1

MISSISSIPPI COUNTIES PARTICIPATING
IN PROJECT CARE-SOM

Southern Zone

Central Zone

Northern Zone

Jasper

Smith

Humphreys

Jones

Simpson

Sharkey

Covington

Copiah

Washington

Wayne

Claiborne

Holmes

Jefferson Davis

Warren

Sunflower

Marion

Hinds

Bolivar

Lamar

Rankin

Tallahatchie

Forrest

Scott

Leflore

Perry

Leake

Montgomery

Greene

Madison

Grenada

Pearl River

Yazoo

Yalobusha

Stone

Carroll

George

Attala

Harrison

Helicopters and coordinated communication
systems have been demonstrated with excellent
results in urban areas as rescue and evacuation
vehicles for highway accident victims. In rural
areas, the paucity of accidents and the vast area
in which they might occur team together to pre-
sent a formidable challenge to the helicopter and
ground ambulance system. Mississippi was chosen
as a rural area for testing the demonstration
project.

A demonstration grant from the National Bu-
reau of Highway Safety, U. S. Department of
Transportation, is funding the Coordinated Acci-
dent Rescue Endeavor-State of Mississippi. Rep-
resentatives of the Governor's Highway Safety
Program are cooperating in an advisory function.

DEMONSTRATION AREAS

Three demonstration areas containing 38 coun-
ties were selected. See Table 1 for a listing of the
counties for each zone. A 50-mile radius zone
was selected for each area based upon the op-
erating capabilities of the helicopter. Headquarters
for the zones are as follow: Northern Zone —
Greenwood; Central Zone — Jackson; Southern
Zone — Hattiesburg. One helicopter, capable of ac-

258

JOURNAL MSMA

Figure 3. Emergency helicopter air and ground
crews demonstrate technique of boarding patient in
specially designed litters. High position of rotary

wing permits loading with poM-er or: for immediate
takeoff.

commodating a pilot, medical attendant, and two
litters, is on alert in each of the zones during a 14-
hour period each day. The 14-hour period was
statistically determined and covers the time peri-
od during which about $5 per cent of the traffic
accidents in the selected zones occur. The project
is designed so that the helicopter will serve as a
supplement to the ground ambulance service. An
effective emergency medical care system cannot
exclude provisions for ground service. Weather
conditions are recorded on each flight, and the
helicopter performance is evaluated.

CONCEPT OF OPERATION

H ere is an outline of the general concept of
operation that Project CARE-SOM employs:

1. Participating ground ambulance companies
with trained crews and coordinated communica-
tion systems are on alert at all times in each of
the zones. The helicopter team is on alert during
selected hours of the day and night.

2 When an accident occurs, either the heli-
copter or ground ambulance, according to plan

and location, is dispatched by the highway pa-
trol.

3. The trained attendants rescue and perform
triage upon arrival at the scene and then evacuate
the injured to the nearest facility capable of pro-
viding definitive treatment.

Two-way radio communications are essential,
and the radio communication needs of this proj-
ect include : 1 ) two-way radio communication be-
tween helicopter dispatcher and helicopter: 2
two-way radio communications between helicop-
ter. ground ambulances, and emergency sendee
wards of hospitals participating in the project: 3 >
two-way radio communications between the heli-
copter and highway patrol vehicles at the ac-
cident scene: and 4) two-way radio communica-
tions between the helicopter and surrounding air-
pons.

In addition, the section of U. S. Highway 49
between Collins. Mississippi, and W iggins. Mis-
sissippi. is equipped 'with roadside emergency
telephones spaced approximately five miles apart.
These telephones are located at interchanges or
crossover points so that they are available to

259

MAY 1970

EMERGENCY SERVICE / Shell et al

motorists approaching from either direction. The
phones are trunked to three main lines; the re-
moval of the handset from any one of these tele-
phones will place the calling party in voice con-
tact with the dispatcher at the Hattiesburg High-
way Patrol Station.

UMC TRAINING COURSE

Before initiating operations, all participating
ambulance and helicopter attendants received a
training course organized and taught by the Uni-
versity Medical Center under the direction of Dr.
William A. Neely. The purpose of this training
course was to teach ambulance personnel resusci-
tative techniques and to train personnel in the
correct procedure to minimize injury during trans-
port of the injured to medical care. The medical
aspects of the course were covered in approxi-
mately 17 one-hour periods and presented to
small groups of students.

Data is being collected by participating hos-
pitals and ambulance services for the evaluation
of several areas of the emergency medical sys-
tem. Time and distance records are being com-

Figures 3 and 4. Highway Patrol trainees simulate
emergency patient transportation in near-real-life ex-
ercise on Interstate Bypass at Jackson. Helicopter is
seen in background with Patrol unit and auto wreck

piled to evaluate the time-response characteris-
tics of the emergency medical system.

NUMERICAL SCALES

With the aid and advice of cooperating physi-
cians, numerical scales have been devised which
(a) indicate the casualty’s condition at the time
he arrived at the hospital, and (b) indicate, for
helicopter transported casualties, the seriousness
of a delay in reaching emergency facilities. These
two scales when used in conjunction with the time
history of the accident (from 1 above) indicate
the benefit which might result from the use of a
helicopter.

The attendant on each mission is required to
file a report and the doctor receiving the case at
the hospital also provides a report that includes
a description of the actual injuries suffered in the
accident. It is expected that from a comparison
of these reports (a) the relevance of the attend-
ant training program to the actual practice may
be evaluated and (b) subject areas in the train-
ing program needing modification will be identi-
fied.

After three months of operation, over 1600
data forms have been returned and are in the

positioned on scene with “injured’ manikin. Right,
wide access port shows litter configuration for multi-
patient transportation in helicopter.

260

JOURNAL MSM A

process of being evaluated. Over 400 life-saving
missions were flown during the same period. With
115 radio units installed and operating in hos-
pitals, ambulances, helicopters, and Highway Pa-
trol Stations, the communications network is being
evaluated and improved.

Through Project CARE-SOM, the Engineer-
ing and Industrial Research Station of Missis-
sippi State University is fulfilling its obligation of

service to the populace of the state. It is hoped
that this demonstration project will serve as a
model for greater effectiveness in emergency
medical care, benefiting not only the people of
Mississippi, but the people of the entire United
States as similar programs are put into effect in
other areas of the nation. ***

P. O. Drawer DE (39762)

NOT BY BREAD ALONE

The CHAMPUS Department at the state medical association
headquarters office sometimes finds it necessary to write program
beneficiaries for supplemental information to substantiate claims
payment. One such letter went to the wife of a serviceman at
Meridian.

Replying tardily with the information, the lady apologized for
a delay explaining that “apparently, my four-year-old son or two-
year-old daughter ate your form letter but with no apparent ill
effects.”

MAY 1970

261

Clinicopathological Conference XCVI

ALVIN E. BRENT, JR., M.D., and LOUIS SCHIESARI, M.D.

The Department of Pathology
Mississippi Baptist Hospital
Jackson, Mississippi

A 51 -year-old, white man was admitted to the
Baptist Hospital because of fever. He had been
well until two months prior to admission when he
injured the gum of the right maxilla with a den-
ture. He had not been able to eat satisfactorily
since. He consulted an oral surgeon who detected
a red spot in the gum of the right maxilla. A
culture taken from this area yielded B. coli and
beta hemolytic streptococcus organisms. The le-
sion cleared up on Neomycin treatment. At this
time the patient developed severe diarrhea,
thought to be gastroenteritis, which was com-
pletely controlled after a week of treatment.
Since then the patient had continued to run fever
periodically, usually higher in the late afternoon.
He felt weak, and a few days before admission
he was noted to be slightly jaundiced. Past history
was not remarkable and not contributory.

On admission the temperature was 101.4°,
the pulse 76, and blood pressure 140 systolic,
80 diastolic. The physical examination revealed
a well-developed, well-nourished, white man with
a slightly icteric color of skin and conjunctivae.
There was a raw, whitish, sore area on the right
upper gum and soft palate. The heart and lungs
were not remarkable. The abdomen was protu-
berant. No definite liver edge was palpable al-
though the patient was extremely tender over
this area. No masses or other organs were pal-
pable. There was suggestion of free fluid in the
abdomen.

The hemoglobin was 9 gm. per cent and the
WBC 8,000, with 72 polys, 23 lymphocytes,
and 5 per cent monocytes. The urine was nega-

tive. Serum chemistry gave the following results:
glucose 105 mg. per cent; BUN 13 mg. per cent;
calcium 9.4 mg. per cent; cholesterol 185 mg.;
phosphorus 4.1 mg. per cent; uric acid 2.7 mg.

The patient in this month’s CPC is a
5 1 -year-old white man admitted because of
fever. He had been well until two months
before admission when he injured the gum
of the right maxilla with a denture. He had
not been able to eat satisfactorily since. Oth-
er symptoms included severe diarrhea, weak-
ness and slight jaundice.

per cent; total protein 6.3 gm. per cent; albumin
3.25 gm. per cent; LDH 200 mU. (Normal 90-
200); SGOT 125 mU. (10-50); alkaline phos-
phatase 465 mU. (30-85); total bilirubin 1.6 mg.
per cent; direct bilirubin 0.74 mg. per cent (nor-
mal less than 0.26 mg. per cent); ammonia 68
meg. per cent (18-48 meg. per cent).

X-ray studies revealed normal lungs and GI
tract, a moderately enlarged heart, and failure of
the gallbladder to concentrate the dye. No stones
were found. The patient was discharged, im-
proved, after 12 days.

While at home he consulted an internist who
felt that the patient had cirrhosis of the liver
and treated him accordingly. At this time the pa-
tient stated that his alcohol intake had always
been very moderate, and that his dietary routine

262

JOURNAL MSMA

Figure 1

had not been good in that he had eaten very
little of high protein foods.

He was admitted to the Baptist Hospital three
months after discharge because of progressive
weakness and worsening of his oral lesions. The
temperature, which on admission was 102°,
maintained an intermittent character during the
entire hospitalization. Examination of mouth by
the oral surgeon revealed a large area in the
right maxilla and posterior soft palate that ap-
peared very much to be a malignancy. A biopsy
was to be performed as soon as the patient’s
condition permitted.

LABORATORY FINDINGS

The WBC was 12,300, with 68 segmenters
and 13 bands. The serum chemistry showed ap-
proximately the same abnormalities found in
the previous admission. The BSP retention was
24 per cent, and serum electrophoresis re-
vealed a normal pattern. The overall appearance
of a liver scan was believed to be quite com-
patible with either cirrhosis or fat infiltration of
the liver. X-rays of upper GI tract and chest were
within normal limits. The spleen was seen to be
enlarged.

The patient complained of dizziness, of cramps
in arms and legs; he was frequently nauseated,
and vomited occasionally. The attending physi-
cian thought the patient was on an impending
hepatic encephalopathy although no foetor he-

paticus could be detected. The patient expired 1 1
days after admission.

DISCUSSION

Dr. Alvin E. Brent, Jr.: ‘This case is some-
what confusing. I am not at all certain of the
diagnosis. We’ll review the protocol for anyone
who might not have read it. This is a 51-year-
old, white male who was admitted here because
of fever. He had been well until two months be-
fore admission when he had some type of injury
to his right maxillary area. Since that time he had
had some difficulty eating. An oral surgeon de-
tected a lesion, and this area was cultured. A
coliform organism and hemolytic streptococcus
was isolated. I think likely that these two or-
ganisms were not of too much importance in his
overall illness. This lesion cleared on Neomycin
treatment. I assume this was oral therapy.

“He developed a severe diarrhea, and this was
probably due to Neomycin which can cause di-
arrhea either due to suppression of the normal
bacterial flora or through direct toxicity to the
mucosa of the bowel. The diarrhea cleared after
some type of treatment, not specified in the pro-
tocol. Following this he continued to be febrile.
He developed some weakness, and was stated to
have become jaundiced several days before ad-
mission here. His history was said to be other-
wise unremarkable.

MAY 1970

263

CPC / Brent et al

“At the time of admission his temperature was
101.4, pulse 76, and blood pressure 140/80. This
pulse represents a relative bradycardia which at
least would make us consider several possibilities.
One of these would be some type of Salmonella
infection such as typhoid fever; also, tularemia
and brucellosis. A number of viral illnesses are
associated with relative bradycardia. Also, any
disease which is associated with increased intra-
cranial pressure could cause this.

PHYSICAL EXAMINATION

“On physical examination, he was noted to be
well developed and to be icteric. We have a le-
sion in the right upper gum and soft palate de-
scribed as erythematous and ulcerative. Heart
and lungs were negative. The abdominal exami-
nation revealed tenderness over the liver area
and was felt to have some ascites. No masses were
noted. Laboratory data showed that he was ane-
mic; his white count was normal, and he had a
normal differential. This would tend to lead us
away from some type of bacterial infection.

“Urinalysis was negative. Chemistries were:
glucose 105 mg. per cent, BUN 13 mg. per cent,
calcium 9.4 mg. per cent, cholesterol 185 mg.
per cent, phosphorus and uric acid both normal.
Proteins were normal. Then we are given several
abnormal liver tests. The LDH was at the upper

Figure 2

limits of normal. He had some moderate elevation
of the SGOT, and a fairly marked elevation of
alkaline phosphatase. His total bilirubin was 1.6,
with a slight elevation of the direct reacting frac-
tions. It is interesting that with a total bilirubin
of 1.6 that he clinically was described as being
jaundiced. Usually this can't be detected until
2.5 or 3 mg. per cent or so, but perhaps the little
elevation of bilirubin and the anemia together, at
least, made him appear jaundiced.

“The blood ammonia was elevated. There is
very little other than liver disease that would
elevate the blood ammonia. On looking into this,
about the only other things to consider would be
therapy with ammonium chloride and use of the
diuretic, Diamox.

“X-rays of the lungs and GI tract were es-
sentially normal. He is described here as having
moderate cardiomegaly. Later this was not men-
tioned. The gallbladder did not concentrate the
dye, and then it is mentioned that there were no
stones found. I’m not sure whether later maybe
it was visualized or just what, but you wouldn’t
expect to find stones if the gallbladder didn’t
pick up the dye anyway.

“After 12 days he was discharged and said to
be improved. Then he saw another physician,
and this physician apparently made a diagnosis of
cirrhosis and treated him ‘accordingly.’ Then we
are given additional history and told that his al-
cohol intake had been moderate and his pro-

Figure 3

264

JOURNAL MSMA

tein intake apparently had not been very good.
Three months after his discharge he was readmit-
ted to this hospital. He was still febrile and re-
mained febrile during hospitalization. From the
description there had been some worsening of the
oral lesions, and apparently they were suspicious
of a malignancy. A biopsy, as the protocol says,
was to be done.

“His serum chemistries were said to be the
same as on his previous admission. His BSP
was markedly abnormal at 24 per cent, but then
it is said that the serum electrophoresis showed
a normal pattern which is perplexing since we
are considering some type of chronic infectious
problem and considering some type of liver dis-
ease, both of which would give an abnormal
electrophoretic pattern. A liver scan was said to
be compatible with cirrhosis or fatty infiltration.
X-rays of the gastrointestinal tract and chest were
normal. He was said to have splenomegaly. He
then developed nausea and vomiting. He was
felt to be in impending hepatic coma, and ex-
pired some 11 days after his admission to the
hospital.

DISEASE POSSIBILITIES

“So, we are presented with the case of a mid-
dle-aged male with an illness which totals ap-
proximately some five months. This illness is
characterized by a febrile course and by involve-
ment of the oropharynx and, also, probably the
liver and questionably the central nervous sys-
tem. It would seem that the main thing then to
consider in the differential would be some type of
destructive process involving the oropharynx and
either a liver disease related to this or possibly
two separate diseases; one of the oropharynx and
another disease of the liver.

“We are at somewhat of a disadvantage in that
we don’t have a lot in the way of positive infor-
mation which makes a differential somewhat
large. I think we have to consider a chronic in-
fectious process as the number one choice. First,
let’s consider the fungal diseases which could pro-
duce this picture. Actinomycosis would seem to
be a good choice. I’ll mention some more about
this later. Nocardia is another fungal disease that
conceivably could give this picture; however, we
would expect to have pulmonary involvement,
and we have a negative chest x-ray in this case.
I think we also would have to consider blastomy-
cosis; however, the absence of skin lesions and,
again, the negative chest x-ray would be against
this diagnosis. Coccidioidomycosis could give this
picture; however, this is the wrong area of the
country, and we aren’t given a history of his
traveling West, and again the negative chest x-ray

would be against this. Histoplasmosis, I think we
would also have to consider; however, again, the
big thing against this, I believe, would be the
negative chest x-ray. I think we would also have
to consider tuberculosis as a possibility. The area
of involvement in the orapharynx would make
you think of bovine tuberculosis; however, the
rarity of this, I think, would be just about ex-
clusive in itself.

Figure 4

“Now, another big group of diseases to con-
sider would be malignancies. A squamous cell
carcinoma arising in the oropharynx with hem-
atogenous spread to the liver would be possible;
however, this would be a very unusual mode of
spread for this type tumor. Another malignancy,
I think, to consider would be an adenocarcinoma
perhaps arising in one of the nasal sinuses with
both local recurrence and hematogenous spread.

GRANULOMATOUS DISEASES

“Then, the last group of diseases to consider
would be one of the destructive granulomatous
diseases which we’ll mention a little bit more of
later. Each of these categories could be associat-
ed with liver involvement, or he could have any
one of these diseases and a separate disease of
the liver.

“I believe I would favor an infectious process
as the number one choice, and of the infectious
diseases I would favor actinomycosis. I’ll try to
support that a little bit. The febrile nature of
his illness would fit well the non-healing oral le-
sion, and the abdominal involvement all would
fit well with actinomycosis. Actinomycosis is a
normal inhabitant of the oral cavity and gastro-

MAY 1970

265

CPC / Brent et al

intestinal tract. Infection usually follows some
type of trauma, and in this case we are given a
history of trauma secondary to apparently poor-
fitting dentures. Another common way for it to
occur is following dental extractions.

“Actinomycosis does spread to bone, with pro-
duction of osteomyelitis, and this could explain
the elevated alkaline phosphatase as could acti-
nomycosis involving abdominal organs or the liv-
er. Actinomycosis also could involve the medias-
tinum, the lung, and chest wall. Also, as I have
mentioned, there is frequently abdominal involve-
ment. Abdominal actinomycosis often follows an
appendicitis or perforation of an abdominal vis-
cus. Abdominal involvement usually presents with
an abdominal mass and draining sinuses over the
abdominal wall, so that it bothers me that in
this case there is no description of masses and
certainly no draining sinuses over the abdominal
wall.

“Central nervous system involvement with ac-
tinomycosis also occurs, and involvement of
heart valves also can occur. You can suspect the
diagnosis of actinomycosis by the finding of
granules termed sulfur granules which drain from
the lesion. They have a characteristic microscop-
ic appearance. The diagnosis should always be
confirmed, however, by culture. At this time there
are no good skin tests for actinomycosis.

ACTINOMYCOSIS

“I would favor actinomycosis as the number
one choice, probably with abdominal involve-
ment, possibly with central nervous system involve-
ment, and possibly with some other widespread
dissemination. As a second choice, perhaps acti-
nomycosis involvement of the oropharynx and an
unrelated liver disease such as Laennec’s cir-
rhosis. As a third choice, I would favor one of
the malignancies which were mentioned.

“As for the last group of the diseases, the de-
structive granulomatous diseases — I’ll just men-
tion these. Lethal mid-line granuloma is a dis-
ease of unknown etiology, characterized by a
chronic course with gradual destruction of fascial
structures. Glanders is a bacterial disease trans-
mitted to man from horses which also is char-
acterized by a chronic cellulitis and destruction
of fascial structures. Other diseases, which should
be mentioned but are less likely, are syphilis,
systemic lupus, and lymphoma. Any one of these
could be associated with chronic destruction of
mucous membranes. If anyone has any further
thoughts, I would be happy to hear them.”

Dr. Louis Schiesari: “At the autopsy table a
large piece of tissue was removed for microscopic
study from the widely ulcerated area involving
the right maxilla and palate. The liver weighed
3,000 gm. It was pale gray, with a smooth, shiny
capsule. The cut surface was again pale gray, not
remarkable, nothing suggesting fatty changes, pas-
sive congestion, cirrhosis, or metastatic disease.
The spleen weighed 500 gm. It was very soft,
friable, with a dark red cut surface, characteristic
changes of acute passive congestion. The adre-
nals (Figure 1) weighed 75 gm. each. They were
symmetrically enlarged, hard in consistency, a
tannish-pale color, again not suggesting metastatic
disease. These were the main changes found at
the autopsy table.

LYMPH INVOLVEMENT

“There was, in addition, moderate edematous
enlargement of abdominal lymph nodes, and the
wall of the large intestine was slightly thickened
and edematous. The microscopic examination
(Figure 2) of the mouth lesion showed an over-
whelming proliferation of histiocytes character-
ized by large cytoplasm. A large number of these
cells contained in their cytoplasms minute pin-
point bodies which on the routine H and E sec-
tion appeared of a purple-red color. These were
diagnosed as histoplasma organisms.

“In order to confirm the diagnosis on H and
E sections the Gomori’s methenamine silver spe-
cial stain was applied. This method (Figure 3),
which stains specifically the capsules of the histo-
plasma capsulatum and of many other fungi be-
cause of the rich amount of mucopolysaccharide
in the capsules, is extremely useful for the ulti-
mate diagnosis in tissue sections. A microscopic
section of one of the adrenal glands (Figure 4)
showed the profound destruction brought about
by the invasion of this organism. Only here and
there a thin rim of cortical adrenal tissue was en-
countered.

LIVER CHANGES

“The liver deserves special mention because of
its anatomical and functional changes. The micro-
scopic examination of the liver sections showed
massive inflammatory infiltration of the portal
areas, the inflammatory cells being chiefly lym-
phocytes with a light sprinkling of polys and
eosinophils. There were also patchy infiltrations
of the same type of cells in the lobules, but the
hepatocytes were well preserved. In spite of the
multiple sections taken, no necrosis or granu-
lomatous reactions were encountered and no or-
ganisms detected by special stains.

266

JOURNAL MSMA

“In summary, the diagnosis was a severe, non-
specific hepatitis, a result of portal drainage from
the large intestine which was severely inflamed,
with organisms also being found. It is interesting
to note the peculiar behavior of the enzymes in
this case. The LDH was within normal limits and
was again in successive determinations; the SGOT
was moderately increased which is not diagnostic
since in many types of liver damage we expect
such a rise. But the alkaline phosphatase was ex-
tremely high, even higher than in any type of
complete extrahepatic biliary obstruction. In this
case the direct bilirubin was only slightly elevat-
ed, and from this finding we can rule out com-
pletely a biliary obstruction.

“This peculiar pattern of slightly increased di-
rect bilirubin and marked rise of the alkaline

phosphatase is very characteristic of a discrete,
patchy, nodular lesion in the liver, either meta-
static or granulomatous. But this was not the
case. It is now well established that of the four
fractions of alkaline phosphatase (hepatic, in-
testinal, placental, osseous) the liver fraction is
produced in the liver itself chiefly by the cells
lining both the small and large biliary ducts. In
this liver, because of the massive inflammatory
reaction in the portal spaces immediately sur-
rounding and infiltrating the biliary ducts, there
was inevitably also some disruption of the lining
cells with spilling of their enzymes into the blood
stream. The result was then a high level of al-
kaline phosphatase in the patient’s serum.” ***

1190 N. State St. (39201)

LIKE FATHER, LIKE SON

A fifth grader was caught reading a “girlie magazine,” and the
teacher marched him off for a talk with the principal. The principal
gave the boy a severe talking to. “Now,” he commanded, “you sit
right down and write a letter to your mother telling what you’ve
done.” The kid sat down and started his letter. “Dear Mother:
This morning I took Dad’s magazine to school and. . . .”

MAY 1970

267

Radiologic Seminar XCV
Multiple Myeloma

JUNE G. BLOUNT, M.D.
Jackson, Mississippi

Multiple myeloma, or plasma cell myeloma,
is the most common malignant primary bone
tumor. This tumor of bone marrow is usually of
multicentric origin, and occasionally develops in
extraskeletal sites. Plasma cell myeloma may
initially appear as a localized lesion, but even-
tually becomes widespread throughout the skele-
tal system. Microscopically, the involved marrow
is replaced by the abnormal plasma cells, and
as the myelomic process expands, it destroys
the adjacent tissue.

The entity is usually seen in individuals over
forty years of age, and bone pain is the most
frequent complaint. Pathologic fracture, anemia,
weakness, neuropathy, paraplegia due to com-
pression of the spinal cord, and recurrent pneu-
monia may be frequent.

The multiple bone lesions, Bence-Jones pro-
teinuria, hyperproteinemia, and the character-
istic plasma cells in the bone marrow form a
diagnostic combination. Paper electrophoresis of
serum and urine detects protein abnormalities
characteristic of multiple myeloma. Associated
findings may include anemia, hypercalcemia,
renal function impairment, atypical amyloidosis,
and increased serum uric acid.

Prognosis is variable in the individual case,
but the mean survival in patients with multiple

Sponsored by the Mississippi Radiological Society.
From the Department of Radiology, University
Medical Center.

myeloma is only nine and a half months from
the time of diagnosis, and 19 Vi months from the
onset of the first symptom (2). Single focus mye-
lomas live longer, but eventually die of dissemi-
nated disease.

RADIOLOGIC FEATURES

Myeloma usually presents as multiple areas
of discrete, round, punched-out osteolytic de-
fects with no reactive sclerosis or periosteal re-
action. Less frequent manifestations include a
single lesion, or diffuse osteoporosis, or rarely,
sclerotic foci. Occasionally, a myeloma lesion
may cause expansion of the cortex or appear
honeycombed. Typical defects may be absent
during the early phase in 25 per cent. Ultimately,
90 per cent will demonstrate one or more osseous
changes.

Bones most frequently involved are the skull,
thoracic cage, spine, pelvis and proximal ex-
tremities. Multiple osteolytic defects are com-
monly found in the parietal and frontal bones
of the skull (Fig. 1). Ribs may appear honey-
combed, or expansile, with soft tissue masses
bulging into the lung fields. The outer end of the
acromion is frequently involved, even when re-
maining portions of the clavicle and scapula are
uninvolved. Diffuse osteoporosis may lead to col-
lapse of vertebral bodies (Fig. 2). Multiple ver-
tebrae may present a bubble-like appearance,
with extension into the vertebral processes, and

268

JOURNAL MSMA

Figure 1. The skull in multiple mye-
loma presents multiple punched-out os-
teolytic defects with no reactive sclerosis.
This 5 2 -year-old female had widespread
skeletal lesions.

Figure 2. The entire cervical spine is in-
volved with diffuse osteolytic lesions. The body
of the fourth cervical vertebra has collapsed
and there is sharp angulation of the spine in
this 44-year-old male.

MAY 1970

269

RADIOLOGIC SEMINAR / Blount

associated paraspinous soft tissue masses. In the
long bones the lesions may enlarge, coalesce and
lead to pathologic fracture of the femur or hu-
merus. In the pelvis, small and large lytic defects
are common (Fig. 3).

The radiographic findings may be indistinguish-
able from metastatic carcinomatosis or hyper-
parathyroidism.

Figure 3. A pathological fracture extends through
the large osteolytic lesion in the left iliac wing. The
pubic rami and femoral neck are involved. This 73-
year-old male presented with a pathological fracture
through a lytic lesion in the distal humerus the pre-
vious year.

Excretory urography is generally considered
to carry some risk in patients with myeloma,
with the occasional development of acute renal
failure following the procedure. This complica-
tion is attributed to tubular obstruction result-
ing from the aggregation of protein, maximal
precipitation occurring between pH of 4.5 and
and 6.0 (4). Dehydration in preparation for
urography predisposes to the precipitation of
myeloma protein in the tubules. Although copious
hydration may help prevent the development of
anuria, the need for urography should be care-
fully evaluated in patients with known myeloma,
as it is impossible to determine prior to roentgen-
ography which patient will develop anuria. (3).

★★★

2500 North State Street (39216)

REFERENCES

1. Ackerman and del Regato: Cancer, 3rd Edition. St.
Louis, The C. V. Mosby Co., 1962, pp. 1142-1170.

2. Craver, L. F., and Miller, D. G.: Multiple Myeloma.
Cancer 16:142-155, July-Aug. 1966.

3. Gross, Melvin, McDonald, Harold, Jr., and Water-

house, Keith: Anuria Following Urography with

Meglumine Diatrizoate (Renografin) in Multiple
Myeloma. Radiology 90:780-781, 1968.

4. Lasser, E. C., Lang, J. H., and Zawadzki, Z. A.: Con-
trast Media: Myeloma Protein Precipitation in Urog-
raphy. J.A.M.A. 198:945-947, Nov. 21, 1966.

5. Meschan, Isadore: Roentgen Signs in Clinical Prac-
tice, Vol. I. Philadelphia, W. B. Saunders Co., 1966,
pp. 278-280, 393, 508-510.

6. Paul and Juhl: The Essentials of Roentgen Interpre-
tation, 2nd Edition. Hoeber Medical Division, Harper
and Row, Publisher, 49 East 33rd St., New York,
N. Y. 10016, 1965, pp. 160-161.

VENGEANCE IS MINE

Three motorcycle bums, replete with leather jackets, boots, and
beards, swaggered into a truck stop restaurant and ordered beer.
Noticing a truck driver eating, they snatched his steak away,
grabbed his bread, and threw his cup of coffee on the floor.

The truck driver said nothing, got up from his seat, and paid
his bill with a smile. When the three cycle bums finished their
beer, they commented to the cashier: “That truck driver isn’t
much of a man, is he?”

“No,” replied the cashier, “and he isn’t much of a truck driver,
either. When he left, he ran over those three motorcycles parked
outside.”

270

JOURNAL MSM A

NATIONAL AND REGIONAL

American Medical Association, Annual Conven-
tion, June 21-25, 1970, Chicago, Clinical Con-
vention, Nov. 29-Dec. 2, 1970, Boston. Ernest
B. Howard, Executive Vice President, 535 N.
Dearborn St., Chicago, 111. 60610.

Southern Medical Association, 64th Annual
Meeting, Nov. 16-19, 1970, Dallas. Mr. Rob-
ert F. Butts, Executive Director, 2601 High-
land Ave., Birmingham, Ala. 35205.

STATE AND LOCAL

Mississippi State Medical Association, 102nd An-
nual Session, May 11-14, 1970, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Howard A. Nelson, 308 Fulton
St., Greenwood, Secretary.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-
taurant, Hernando. Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday,
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, April and October. Cherie Friedman,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October, Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell. 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March,
June, September, and December. A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday,
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.
W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m., Old Southern Tea Room, Vicksburg.
Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

MAY 1970

271

The President Speaking

Past and Future: The Task Ahead

JAMES L. ROYALS, M.D.

Jackson, Mississippi

As we make plans for the state convention in Biloxi and as I
write this, my last editorial as President of the State Medical
Association, it seems only natural to reflect on the events of the
last year.

The year has been dominated by two sessions of the state
legislature which considered many bills of major importance to
medicine, the foremost of which was Medicaid. While in general
we were warmly received by the Legislature, it became painfully
apparent during the year that we have lost much of the rapport
that we formerly enjoyed. With big government, both state and
federal, moving massively into the health care field, it is urgently
necessary that we do some fence mending with our friends in the
Legislature.

The second reflection which comes to mind is that controls on
medicine were on-rushing from outside sources; and these con-
trols are coming in large part because of our own reluctance to
exercise a proper police of our own ranks. A mechanism, through
peer review committees, is being set up to correct this. Our own
self-interest demands that it be effective. If we are to retain the
free-enterprise system of medical care, we must continue to prove
it to be worthy.

In order to successfully meet the efforts of those who would
make the health care team a vassal of the state, it is necessary
that all physicians actively participate in organized medicine. We
have a democratic organization which needs to be constantly up-
graded and improved so that the unified voice of medicine will be
loud and clear. We have a good organization. To meet our re-
sponsibility to the public, let us work to make it better.

Lastly, it is with deep appreciation that I thank the members
of the State Medical Association for the warmth with which
Mary Alice and I have been received in our travels about the
state. ***

272

JOURNAL MSMA

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 5

May 1970

The Family Practice Specialist:

Medicine’s New Man

T

My husband has practiced medicine for 20
years,” the wife of a Mississippi family physician
recently observed with whimsical humor, “and
now they are going to give him an examination
to see if he is qualified to be a general prac-
titioner.”

This is not an unusual reaction to the concept
of medicine’s newly-emerged discipline, family
practice, replete with certifying board, specialty
society, the blessings of AMA, and a fistful of
credentials which may change the organization
of care delivery. Some have scoffed at the very
idea of “certifying a man to do everything” when
it takes up to five years to know something
about a single specialty. It is in this critical ap-
praisal of family practice that the key to under-
standing of the concept may lie.

For one first thing, the diplomate of the Amer-
ican Board of Family Practice shall not have
demonstrated total proficiency in the 19 other
specialty disciplines. He, above all physicians
readily recognizes that, and he will depend heav-
ily on his fellow specialists in the care of his pa-
tient as he does today. Only he will do it in a
different manner and context of professional ap-
proach. His is an inclusive rather than exclusive
specialty, and he is a sort of third-generation

generalist. Explaining this, Dr. Vernon Wilson,
vice president for Academic Affairs of the Uni-
versity of Missouri, says that “his approach to
medicine will be built on the foundation of yes-
terday’s country doctor and today’s general prac-
titioner, but developed from that foundation in-
to something different.”

That something different is what we must un-
derstand and appreciate. This new breed of
M.D. could be the answer to growing problems
in organizing the delivery of medical care.

II

Among words of praise flowing from the elo-
quent pens of today’s writers are characterizations
of the pathologist as medicine’s indispensable
man, of the transplant surgeon as the scientist
ahead of the astronauts, of the internist as medi-
cine’s infallible detective, and on to the anes-
thesiologist as the comforter who has made the
surgeon successful. Frankly, about the most writ-
ten of late about the general practitioner is that
he is the vanishing American. Now he promises
to re-emerge as a vital, exciting quantity with a
horizon of service beyond most hopes: He in-
tends to treat people instead of things.

The new specialty board came to full term
and delivery with not a few antepartum compli-

MAY 1970

273

EDITORIALS / Continued

cations. The AMA House of Delegates, whose
endorsement was crucial, didn't buy the package
without knowing the contents. The Ad Hoc Com-
mittee on Education for Family Practice, a body
of AMA, labored long and hard with the medi-
cal educators, the Advisory Board to the Medi-
cal Specialties, the AMA Council on Medical
Education, and state medical associations. The
American Academy of General Practice made a
reasoned decision on the entire idea, not with-
out lively and even stormy debate.

AAGP defines the family specialist as a phy-
sician who:

— Serves his patient as the physician of pri-
mary contact, the portal of entry into a better-
organized health care system.

— Makes an evaluation of total health care
need, treating some conditions himself and re-
ferring the patient to other specialists as neces-
sary while maintaining care continuity.

— Accepts responsibility for continuous and
comprehensive care while acting as the coordi-
nator of services.

— Views the patient’s medical requirements
within the context of the environment, the family
unit and the community.

This specialist, then, is as much of an advocate
as a physician. Dr. Wilson compares the family
physician to an attorney on continuing retainer
as opposed to a source of one-time, episodic
service. He must emphasize preventive services
more than curative services within the family
unit if his new role is to become more than words.

Ill

All of this adds up to a new kind of medical
education, and this is a knotty problem for the
specialty. There must be students, competent
teachers, and specialized departments in medical
schools. Educators must be won over to the cause,
say representatives of family practice, because
too few of the schools have even begun to shape
a curriculum meeting the residency essentials. A
few prophets of gloom feel that an insufficient
number of students will be interested, even when
the new departments are established. More feel
that there are plenty of medical students in-
clined toward family practice and that all they
need is the vehicle.

Nor can the nation’s 70,000 generalists already
in practice be overlooked, let alone relegated to
a lower rung on the medical ladder. There is a
job to do in postgraduate education, including
the selling of the new concept, if the discipline is
to unite rather than fragment. Since nobody gets

certification under a grandfather clause, today’s
general practitioner has the dual tasks of quali-
fying himself and carrying the colors forward for
a training mechanism.

The family practitioner, already established,
has 10 years to achieve certification, but if he
has been in practice for at least six years and can
show that he has satisfactorily completed 300
hours of postgraduate work acceptable to the
American Board of Family Practice, he is deemed
eligible to sit for the examination. A medical
educator who has been on the job for six years is
similarly eligible. The first examination was con-
ducted in February of 1970, a scant year after
the new specialty saw the light of day.

IV

Everybody is talking and writing about the
delivery of medical care, the system, its orga-
nization, financing, and mostly, its problems.
Some go so far as to say that there isn’t a deliv-
ery system at all. Many mistake medical care
financing as a delivery system, when this is only
a part. Hard-line proponents of prepaid group
practice — closed panels to most of us — argue
that organization is everything and that under
group practice, financial problems take care of
themselves.

“ Doctor Quigley? — About that sheep’s kidney you
put in me . .

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JOURNAL MSM A

Probably nobody is entirely correct on the
matter. There is a delivery system, but anyone
who has any knowledge of it understands that it
is straining at the seams with manpower short-
ages, spiraling costs, overburdened facilities, and
a growing population of consumers who are de-
manding more services. The extension of the
financing base through Medicare, Medicaid, and
growth of health insurance and prepayment has
exacerbated these woes, and now supply and
demand economics are getting some of the fi-
nancing mechanisms in hot water.

Forward-thinking medical men, not necessar-
ily the liberal left decrying traditional delivery
patterns, believe that the organization of care is
destined to change in the 1970’s. We shudder —
not for ourselves but for our patients — when we
think of political “solutions” in national com-
pulsory health insurance, because the inevitable
squeeze on finances must influence quality and
quantity of care.

This is a roundabout way of saying that a care
organizer within the private practice structure
might be the answer. He would make an assess-
ment of need, treat what he can and should,
and call in another specialist where and when in-
dicated. But he would maintain the continuity
and have the competence to do so. Moreover, if
he did his job in preventive care, then at least
some need for drastic, episodic service might be
avoided.

This is admittedly an ideal view, but the new
specialist might just be a key to organization, pre-
vention, and the safety valve on rising costs. But,
we think it appropriate, within the framework of
private care delivery. Carried to the logical con-
clusion, this is the antithesis of bureaucracy, the
end result of just about everything the govern-
ment has arrogated unto itself.

Family practice in this new perspective has
not been hastily conceived, and it makes the
most of the useful past while looking ahead to
make a good thing better. The medical histo-
rian may someday write that this development of
the 1960’s was American medicine’s strongest
forward thrust in its most difficult days. — R.B.K.

Part 1-B Is a
Two-way Street

Distress and unrest is growing among many
physicians who care for patients under Part 1-B
of Medicare. Some are beginning to wonder how
serious the government is about paying a just
and reasonable fee for needed medical services.

And this isn’t an infrequent quirk, either, because
a developing pattern clearly indicates otherwise.

A respected component of the state medical
association, the Northeast Mississippi Medical So-
ciety, was sufficiently concerned to take formal
action over “arbitrary treatment” of physicians’
claims by the Tupelo office of the Travelers In-
surance Co., unanimously adopting a resolution
of protest during a regular meeting.

More than a handful of physicians in the south
and southeastern areas of the state have raised
their voices in protest over the handling of Part
1-B Medicare claims at the Hattiesburg office.
And there are more — more physicians and more
instances of protest.

Chief among complaints recorded is imposi-
tion of limitations on care, such as replying that
one visit to a physician every two weeks is suf-
ficient for treatment of a given condition. The
squeeze on fees, now pegged at the 75th per-
centile of 1969 levels, often shows up in strange
contrast to the initially unctuous policy of paying
usual and customary charges based on prevail-
ing levels in a community or socioeconomic area.

The Mississippi State Medical Association is
firmly on record as condemning overutilization
of any medical care financing mechanism. It sup-
ports peer review, fair and impartial application
of the usual and customary concept under which
adjustments of fees can be made, and profession-
al judgment implicit in professional responsibil-
ity. These are not just pretty words, empty of
content, and uttered to get a high-sounding but
sterile policy on the record. These are serious
expressions of warranty upon care delivery as-
surances, and the association cannot regard light-
ly any action by a medical care financing mecha-
nism which accepts the commitment but ignores
the judgment.

Even more distressing are some actions in
processing unassigned Part 1-B claims where the
carrier’s obligation ends with payment of the al-
lowable amount to the beneficiary. There are
recorded instances of the carrier’s advising bene-
ficiaries that their responsibility to the physi-
cian has been satisfied.

The Journal has only recently observed edi-
torially that the government is inclined to strain
at a gnat while swallowing a camel. Most of the
incidences cited are gnats compared to the camel
of concomitant hospital charges. But then again,
the physician is a single entity, devoting long
hours to care of his patients, and the easy target
for the claims examiner’s blue pencil.

The association has no reservations about in-
terpreting “reasonableness” in care delivery. But
this is a two-way street where the traffic rules do

MAY 1970

275

EDITORIALS / Continued

not permit a traveler to drive on both sides. This
has been made clear in meetings of the associ-
ation’s Health Insurance Benefits Advisory Com-
mittee with representatives of HEW, the Social
Security Administration, fiscal intermediaries, and
the Part 1-B carrier. There are indications that
the association has become increasingly concerned
over these distressing developments. Physicians
have made a sincere commitment, and they ex-
pect others to do no less. — R.B.K.

The Nelson Syndrome
and Pill Complications

Sen. Gaylord Nelson (D., Wis.), the solon ac-
cused of “causing 100,000 unwanted pregnan-
cies” with the one-sided hearing on oral contra-
ceptives, may have triggered another series of
phenomena. The Association for Voluntary Ster-
ilization reports that 100,000 persons a year are
requesting permanent sterilization. Three out of
four applicants are men.

Blue Cross plans in 30 states pay hospital costs
for inpatient sterilization procedures, mostly for
medical reasons. Medicaid pays in 35 states on
the same basis. CHAMPUS universally pays for
sterilization for medical reasons, every vasectomy
for husband where the procedure is contraindi-
cated but necessary for the wife. The state medi-
cal association’s CHAMPUS Department reports
that vasectomy is becoming more frequent under
the program.

Still another development growing out of the
Nelson hearings on the pill is an upsurge in sales
of mechanical contraceptives. One manufacturer
of diaphragms said that demand is up 500 per
cent for his product. Another mechanical contra-
ceptive maker announced the first mass market
consumer advertising campaign with purchase of
space in Playboy , Ebony, and Modern Bride.

The recently-ordered package insert for pa-
tients in oral contraceptives may undermine usage
further, bringing more unusual developments. All
of this comes in the face of compounded prob-
lems in the population explosion, growing wel-
fare programs, and strains on medical resources.

When the consensus of reasoned medical opin-
ion holds that benefits of oral contraceptives far
outweigh any risks inherent in their use, Sen.
Nelson has performed a disservice to the public.

He intensifies many of the toughest problems i
confronting the Congress of which he is a mem-
ber. He has made use of scare tactics, the most
unscientific approach possible to any issue, eroding
scientific credibility and public confidence. This
is the Nelson Syndrome which may be correctly
described as an insidious entity of doubt capable
of exacerbating social ills and accelerating eco-
nomic debilitation. — R.B.K.

Medical Corpsmen,
New Manpower Pool

Learn a new word: MEDIHC. It is an acronym
for Military Education Directed Into Health Ca-
reers, and it’s all about medics who are sepa-
rated from the military services. Traditionally,
hospitals and other medical institutions have
found that former military medical corpsmen leave
the service with useful and often immediately
applicable skills. The manpower shortage is mak-
ing medicine take a closer look at these service-
men.

Operation MEDIHC is a joint program of the
Departments of Defense and HEW aimed at uti-
lizing the skills of former service personnel who
were assigned to medical duties. A number of
medical societies have expressed the belief that
former medical corpsmen make the best “physi-
cian’s assistant,” equal to the baccalaureate degree

“It all depends . . . What type of hospitalization
plan do you have?"

276

JOURNAL MSMA

trainees now coming out of Duke and the Uni-
versity of Colorado.

Nearly 30,000 medical corpsmen are discharged
by the armed services each year. Even small
utilization of this significant pool will be immense-
ly helpful in easing the health service manpower
squeeze. Last year, it was demonstrated that 15
per cent of these separatees were immediately
employable in the health care field. Another sur-
vey discovered that 60 per cent of the corpsmen
were interested in obtaining additional education.
The 1969 scoreboard shows that 19 per cent of
those separated went into health service jobs
full time, while 22 per cent went into combina-
tion work-training, i.e., student technologist, situ-
ations. This is an impressive salvage of scarce
talent.

The program is a brainchild of AMA which
first offered the Department of Defense medical
advisory services in health careers. Now, pre-
separation counseling is being offered soon-to-be-
discharged medics at 214 domestic military in-
stallations. Clearinghouse centers have been es-
tablished to exchange information on individual
qualifications and educational requirements for
higher qualification on dischargees.

The program promises to increase the number
of former corpsmen entering the civilian health
care field by 5 per cent per year through 1975.
This is a meritorious program, deserving of med-
icine’s support and assistance. — R.B.K.

The Cost Dilemma of
Hospital Services

Ready for a shocker? Then try this: Hospital
costs in 1969 were twice as much as Franklin
D. Roosevelt’s national budget in 1940!

Last year, according to the American Hospital
Association, the nation’s 5,820 community hos-
pitals experienced a cost increase of 17.2 per
cent over 1968 for a total of $17 billion. That’s
just under a third of the sum total of health
care costs and a rise of $2.5 billion over the pre-
ceding year. Informed observers had predicted
a rise of 15 per cent, but they were a little con-
servative.

AHA says that supplies and equipment are
the villains, rather than personnel, although the
costs of people went up 12 per cent for the in-
stitutions. Translated into costs per patient day,
this means that the average was up $9.15 over
1968 for a whopping national mean of $68.41.
But translated again onto the patient’s bill, it is
nearer $75 per day.

The outlook isn’t bright, either, for the rate of
rise is seen as a constant for two more years
“as the hospitals’ wage scales catch up with other
industries,” according to AHA. Back in the mid-
1960’s when economic savants predicted that
hospital per diem costs would hit $100 per day
by 1975, most folks doubted or simply laughed.
Nobody is laughing now as we perceive just how
much the economists were off. Already, many
metropolitan hospitals have exceeded $100 per
day.

In 1969, 28.4 million Americans were ad-
mitted to hospitals, up about 2 per cent over
1968. Medicare admissions increased over 6 per
cent, an understandable outcome of the grow-
ing segment of seniors and of the longer life. The
average patient stay was 8.1 days, the same as
1968, while the average stay for Medicare and
other over-65 patients, decreased to 13 days
from the previous 13.4 days.

Outpatient departments in hospitals are grow-
ing by leaps and bounds, racking up 118 million
visits in 1969. Hospital employment went up
by 100,000 workers to a record 1.8 million.

Hospitals are challenged to discover and ap-
ply management innovations to put the brakes on
the costs of care. Gradients of care intensity
are more urgently needed than ever before,
both for conservation of high-priced, short-sup-
ply manpower and for the sheer economics of how
the bill can be paid. The not-so-funny joke that
only the very rich and the very poor can afford
to be in the hospital is a little more aphoristic
than facetious. — R.B.K.

May 28, 1970

CARDIOPULMONARY
RESUSCITATION
TRAINING PROGRAM

Limited to 15 physicians, this one-day
course is designed to train MRMP-CPR
instructors in cardiopulmonary resuscitation
techniques. The course, presented jointly by
the Mississippi Heart Association and the Uni-
versity of Mississippi School of Medicine, will
feature individual instruction in cardiac and
respiratory resuscitation using the manikins
and care of the manikins. An attorney will
speak on laws involving cardiac arrest. Dr.
Leonard Fabian, anesthesiology chairman, is

MAY 1970

277

POSTGRADUATE / Continued

coordinator for the seminar. Registration will
be at 8:30 a.m. in the School of Nursing.

CIRCUIT COURSES

Eastern Circuit

Meridian — May 5 — Session 3

Briarwood Country Club, 6:30 p.m.
Session 3 — Complications Associated with
Saddle Block Anesthesia in Obstetrics,
Dr. Donald Sherline

The Management of Edema Related to
the Kidney, Dr. Ben B. Johnson

FUTURE CALENDAR
May 11-14

Mississippi State Medical Association
May 28

Cardiopulmonary Resuscitation
Training Course

John K. Abide of Cleveland spoke at the March
meeting of the North Delta District Nurses’ As-
sociation on the importance of the doctor-nurse
and nurse-patient relationships for quality pa-
tient care.

George Allard of Flora, Paul B. Brumby of
Lexington, William H. Parker of Heidelberg,
Tom Herron Mitchell of Vicksburg, Howard
D. Clark of Morton, and John G. Atwood of
Meridian have been re-elected to active mem-
bership in the American Academy of General
Practice. Re-election signifies that the physician
has successfully completed 150 hours of accred-
ited postgraduate medical study in the last
three years.

G. Spencer Barnes of Columbus assumed the
presidency of the Mississippi Heart Association
at the annual one-day assembly in Jackson.

F. C. Boren of Mantachie was honored on his
93rd birthday by the Pilot Club of Mantachie.
Dr. Boren still sees patients and has been prac-
ticing for almost 60 years.

Theresa L. R. Buckley of Biloxi has been re-
elected president of the Altrusa Club of Biloxi.
Dr. Buckley limits her practice to ophthalmology.

R. G. Burman and D. C. Raines, III, of Gulf-
port announce the removal of their offices, The
Woman's Clinic, to Medical Arts Plaza at 1213
Broad Avenue.

L. J. Clark, Jr., of Vicksburg announces the
removal of his office to 2837 Clay Street. Dr.
Clark limits his practice to internal medicine.

John Downer of Lexington is heading the 1970
educational and fund-raising Crusade of the
American Cancer Society in Holmes County.

A. P. Durfey, John R. Durfey, and A. P.
Durfey, Jr., of Canton have moved into their
new office building located on Country Club
Road near the Madison General Hospital.

Elizabeth Ferrington of Jackson has received
the Service Award of the American Legion for
many years of faithful service to hospitalized vet-
erans. Dr. Ferrington was on the staff of the
Jackson VA Center for many years before re-
cently retiring.

Harry Frye of McComb has been elected to
another term on the South Pike School Board.
Dr. Frye won handily over his opponent 982-234.

On pages 18 and 67 of the 1970 Mississippi Di-
rectory of Physicians, Luther H. Fulcher of
Jackson was listed incorrectly as Luther H.
Fulton.

Wendell N. Gilbert, Sr., of Taylorsville an-
nounces the opening of his office for family prac-
tice in the old Smith County Bank Building.

H. Lamar Gillespie, Marcus Hogan, Ramsay
O’Neal, and William R. Raulston, all of Hat-
tiesburg, have initiated a scholarship program for
two nursing students at the University of Southern
Mississippi School of Nursing.

John N. Harrington and James T. Doster of
Columbus announce the formation of a partner-
ship for the practice of obstetrics and gynecol-
ogy at the Medical Arts Center, 221 7th Street
North.

Elmer J. Harris, James M. Packer, Robert
P. Henderson, and Ottis G. Ball, all of
Jackson, announce the association of Fred A.
Lewis in the practice of radiology at 316 Med-
ical Arts Building and at the Mississippi Bap-
tist Hospital.

Mary E. Hawkins of Jackson announces the

278

JOURNAL MSMA

removal of her office to Suite 205, Medical Arts
Building, 1151 North State Street for the prac-
tice of obstetrics and gynecology.

James H. Hendrix, Jr. of Jackson participated
in the recent annual convention of the South-
eastern Society of Plastic and Reconstructive Sur-
geons in New Orleans. Dr. Hendrix is current
president of the society.

Dan Keel, Jr., of Brookhaven was among the
District Chairmen, Commissioners, and Execu-
tives of eight districts of the Andrew Jackson
Council, Boy Scouts of America, who met in
Jackson recently.

Dewey Lane of Pascagoula has been named
Jackson County’s Outstanding Citizen of the Year.
He was chosen from a field of 17 outstanding
citizens nominated for the annual B&PW award.

William A. Long, Jr., of Jackson addressed
the Central Mississippi Chapter of the Missisippi
Association of Medical Assistants on adolescent
medicine recently. Dr. Long limits his practice to
ephebiatrics.

M. S. Love of Gulfport has been elected a mem-
ber of the Salvation Army Advisory Board and
was installed at the annual banquet and awards
presentation.

The following physicians have been elected to
membership by their respective component med-
ical societies in the Mississippi State Medical
Association and the American Medical Associ-
ation.

Durfey, Allan Percy, Jr., Canton. Born Can-
ton, Miss., Aug. 12, 1937; M.D., University of
Mississippi School of Medicine, Jackson, 1962;
interned Confederate Memorial Medical Center,
Shreveport, La., one year; surgery residency,
same, July 1, 1963-June 30, 1967; elected
Jan. 6, 1970, by Central Medical Society.

Gifford, William Burton, Eupora. Born
Prentiss County, Miss., March 20, 1930; M.D.,
University of Mississippi School of Medicine,
Jackson, 1960; interned University Medical Cen-
ter, Jackson, Miss., one year; pediatric residency,
same, July 1, 1961-June 30, 1962; elected Dec.,
1969, by North Central District Medical Society.

Gore, Edward Kirkham, Houston. Born Hous-
ton, Miss., July 17, 1938; M.D., University of
Mississippi School of Medicine, Jackson, 1964;
interned Carswell APB Hospital, Pt. Worth, Tex.,
one year; elected Dec. 3, 1968, by Northeast
Mississippi Medical Society.

James L. McLain of Tylertown announces
the relocation of his offices in the Doctor’s Clinic
in the old Walthall Hospital building.

William C. Munn of Mendenhall has moved
into his new clinic building.

Joe Glenn Peeler, Jr., of Shaw has been se-
lected for inclusion in the 1970 edition of Out-
standing Young Men of America.

Antone W. Tannehill, Jr., and Lloyd L.
Lummus of Tupelo announce the opening of
new offices at 806 W. Garfield.

James Waites of Laurel has been named chair-
man of the Public Health Committee of the
Laurel Chamber of Commerce’s 1970 “Lorward
Laurel” program.

John R. Young, Jr., of Natchez has been elected
Sergeant- At- Arms of the Natchez Rotary Club.

Hamernik, Robert Joseph, Jackson. Born
Elbowoods, N. D., Nov. 29, 1938; M.D., Uni-
versity of Mississippi School of Medicine, Jackson,
1964; interned University Hospital and Hillman
Clinics, Birmingham, Ala., one year; surgery res-
idency, University Medical Center, Jackson,
Miss., 1965-66; anesthesiology residency, same,
March 1, 1968-Peb. 28, 1975; elected March 3,
1970, by Central Medical Society.

Lynch, William Prederick, Jr., Jackson. Born
Jackson, Miss., Jan. 30, 1934; M.D., University
of Mississippi School of Medicine, Jackson, 1959;
interned San Diego Naval Hospital, Calif., one
year; radiology residency, St. Albans Naval Hos-
pital, Long Island, N. Y., March 1, 1963-March
1, 1966; elected Jan. 6, 1970, by Central Medi-
cal Society.

McPadden, John Wilbur, West Point. Born
Monroe, La., June 26, 1939; M.D., University
of Mississippi School of Medicine, Jackson, 1965;
interned University of Texas Medical Branch,
Galveston, one year; pediatric residency, same,

MAY 1970

279

NEW MEMBERS / Continued

July 1, 1966-June 30, 1968; elected March 10,
1970, by Prairie Medical Society.

Ozborn, Charles Allen, Eupora. Born Union,
Miss., May 26, 1939; M.D., University of Mis-
sissippi School of Medicine, Jackson, 1964; in-
terned Mississippi Baptist Hospital, Jackson, one
year; elected Dec., 1969, by North Central Dis-
trict Medical Society.

Walker, Billy Lake, Tupelo. Born Utica, Miss.,
July 2, 1937; M.D., University of Mississippi
School of Medicine, Jackson, 1962; interned
University Medical Center, Jackson, Miss., one
year; pathology residency, same, July 1, 1963-
June 30, 1965; pathology residency, University
Hospital, Lexington, Ky., July 1, 1965-June 30,
1967; elected Dec. 9, 1969, by Northeast Mis-
sissippi Medical Society.

Wilder, Samuel Jobe, Jr., Jackson. Born Co-
lumbus, Miss., Aug. 18, 1935; M.D., University
of Mississippi School of Medicine, Jackson, 1964;
interned Duval Medical Center, Jacksonville,
Lla., one year; orthopaedic surgery residency,
Mississippi Baptist Hospital, Jackson, July 1,
1965-June 30, 1967 and University Medical Cen-
ter, Jackson, Miss., July 1, 1967-June 30, 1969;
elected Jan. 6, 1970, by Central Medical So-
ciety.

Cannon, Russell Howell, Bruce. M.D.,
University of Mississippi School of Medi-
cine, Jackson, 1958; interned Moses H. Cone
Memorial Hospital, Greensboro, North Carolina,
one year; surgery residency, University Medical
Center, Jackson, Mississippi, July 1, 1959-July
15, 1963; died March 19, 1970, age 37.

Robertson, Milton Harold, Corinth.
M.D., University of Louisville School of
Medicine, Kentucky, 1942; interned Kosair Crip-
pled Children’s Hospital, one year, and Norton
Memorial Hospital, one year; died March 13,
1970, age 58.

MSBH Screens Greene
County for Medicaid

Greene County is the second county in the
state to come into a State Board of Health pro-
gram for the screening of children entitled to
medical care under the state’s Medicaid program.

The program got under way in Greene Coun-
ty April 1 6 and will continue with screening
clinics each first Thursday and third Thursday
at the county health department at Leakesville.

Dr. Lrank M. Wiygul, Jr., director of the Di-
vision of General PJealth Services, State Board
of Health, said some 400 young people, most of
them between five and 18 years old, will be
screened.

He said the children will be screened for heart
defects, vision defects, hearing defects, tuber-
culosis, anemia and other abnormal conditions.

Dr. James Totten, county health officer for
Greene County, and Mrs. Myrnis McCoy, R.N.,
public health nurse for the county, will coordi-
nate the program at the local level.

Terry Beck, coordinator for the program at
the state level, said parents of eligible children
will be notified in advance of the date and time
for them to bring the children in for screening.

“We urge all parents to come in at the exact
time designated in the notice,” said Beck. “Be-
cause of space limitations, we can only accommo-
date a certain number of people at any one
time.”

The State Board of Health began the pro-
gram March 12 in Warren County and plans ul-
timately to extend the program statewide, as fast
as circumstances permit.

“We selected Greene County as the second
county,” said Beck, “on the basis of need, and
on the basis of the county’s good nursing service
and its ability to follow up on people to be
screened.”

The State Department of Public Welfare is
working with the State Board of Health in the
program, since screening is primarily for those
receiving “Aid to Dependent Children” assist-
ance.

Certification for Medicaid is made through the
State Department of Public Welfare. Most of
those included in the medical screening pro-
gram will be under 18.

State Board of Health officials have estimated
that approximately 90,000 children are eligible
for the screening.

280

JOURNAL MSMA

Book Reviews

Urinary Tract Infection in Childhood and Its
Relevance to Disease in Adult Life. By Victoria
Smallpiece, M.A., M.D., F.R.C.P. 142 pages with
illustrations, St. Louis: The C. V. Mosbv Com-
pany, 1969. $9.50.

This concise little book deals with problems
of recurrent urinary tract infections in childhood
and its sequelae in adult life. The author follows
the subject in chronological order dealing first
with etiology, then diagnosis, treatment, course
and prognosis.

Her discussion of the problems of vesicoureter-
ic reflux is interesting. The author points out that
the correlation between reflux and infection is
well documented and the “incidence of reflux in
patients with pyelonephritis tends to rise with im-
provement in diagnostic techniques.”

The effects of hydration and of osmolarity on
host defence is discussed. While there is consid-
erable volume of evidence that water diuresis
increases the resistance of the kidney to infec-
tion, there are varying views on the reasons for
this. She points out the work of Schlegel and
Burden who believed that since a dilute urine
will also reduce the concentration of sulphona-
mides and of urea, this is contraindicated. They
consider that urea as found in concentrated urine
is bactericidal. Other writers are in favor of in-
creasing urine flow.

The author points out that urinary tract in-
fection in the young child is more liable than
any other common disease to be overlooked by
the parents and misdiagnosed by the medical
profession. Reasons for this include paucity of
symptoms in some cases. “It cannot be too strong-
ly emphasized that reinfection in the course of
chronic pyelonephritis in children of any age can
be completely symptom free.”

Whether every child should have a full uro-
logical investigation including pyelograms, mictu-
rating cystourethrogram, pressure studies and
ladoscopy at the time of the first attack is a
matter of discussion. Most workers are in favor
of at least the first two examinations.

The underlying theme throughout this book is
the importance of diagnosis and treatment of re-
current urinary tract infections in children and.
thus, avoiding the future sequelae of progressive
renal failure and death.

Joel L. Alvis, M.D.

The Practice of Refraction, Eighth Edition.
By Sir Stewart Duke-Elder, M.D., Ph.D., F.A.C.S.
329 pages with illustrations. St. Louis: The C. V.
Mosby Company, 1969. $11.75.

The author states in his preface that no revo-
lutionary changes have appeared in the art of
refraction since the seventh edition. This is true
and is best evidenced by the fact that the preface
and indeed each and every chapter is practically
identical to its predecessor. Several new tables
of a mathematical nature are added.

The art of refraction must first be preceded by
a firm grounding in the principles of optics, the
refractive system of the eye and the anomalies
of refraction. The present text continues to pro-
vide clearly this essential information.

All the illustrations continue to use English
(and outmoded English at that) instruments.
The chapter on contact lens has been used again
without a single alteration. This is unfortunate
as important basic advances have been made in
this particular area.

In summary, this slim text provides a good,
inexpensive and generally complete introduction
to that subject which occupies necessarily an im-
portant niche in the opthalmologist's life.

Richard L. Blount, M.D.

New Books Received

Manic Depressive Illness. By George Winokur,
M.D.. Paula J. Clayton. M.D., and Theodore
Reich, M.D. 161 pages with illustrations. St.
Louis: The C. V. Mosby Company, 1969.
$6.50.

Crisis Fleeting. Original Reports on Military
Medicine in India and Burma in the Second
World War. Compiled and Edited by James H.
Stone. Office of the Surgeon General. Depart-

MAY 19 70

28 1

LITERATURE / Continued

ment of the Army, Washington, D. C, 1969.
$3.75.

Symposium on Cancer of the Head and Neck.
Edited by John C. Gaist’ord, M.D. 362 pages
with 583 illustrations. St. Louis: The C. V. Mosby
Company, 1969. $31.50.

The Vitreous in Clinical Ophthalmology. By
Norman S. Jaffe, M.D., F.A.C.S., F.I.C.S. 300
pages with 334 illustrations. St. Louis: The C. V.
Mosby Company, 1969. $32.50.

Personnel Administration and Labor Relations
in Health Care Facilities. By James O. Hepner,
M.H.A., Ph.D.; John M. Boyer, M.A.; and Carl

L. Westerhaus, M.S. 370 pages. St. Louis: The
C. V. Mosby Company, 1969. $15.00.

Handbook of Psychiatry. By Philip Solomon,

M. D., and Vernon D. Patch, M.D. 589 pages.
Los Altos, Calif.: Lange Medical Publications,
1969. $7.00.

Synopsis of Obstetrics. Eighth Edition. By
Charles E. McLennan, M.D. with collaboration
of Eugene C. Sandberg, M.D. 496 pages with
212 illustrations. St. Louis: The C. V. Mosby
Company, 1970. $9.50.

Current Diagnosis and Treatment. By Henry
Brainerd, M.D., Marcus A. Krupp, M.D., Milton
J. Chatton, M.D., and Sheldon Margen, M.D.
884 pages. Los Altos, Calif.: Lange Medical
Publications, 1970.

Synopsis of Clinical Cancer. Second Edition.
By Condict Moore, M.D. 267 pages with 37 il-
lustrations. St. Louis: The C. V. Mosby Com-
pany, 1970. $ 1 1.75.

Miss. House
Commends MSMA

The House of Representatives of the State of
Mississippi has commended the Mississippi State
Medical Association in House Resolution No. 114.

The House expressed appreciation to MSMA
members for services rendered during the 1970
regular session of the Legislature.

In the resolution adopted March 30 and signed
by Speaker John R. Junkin, the legislators ex-
pressed special thanks for services doctors ren-
dered during the recent siege of flu and colds
and various other illnesses.

The state medical association operates the
Emergency Medical Care Unit in the Capitol
building with a registered nurse on duty. Physi-
cians throughout the state volunteer to serve as
Doctor of the Day during the legislative sessions.

Diabetes Association
Reorganizes in State

The Diabetes Association of Mississippi has
been reorganized to include lay members. Na-
tional regulations of the association formerly
limited membership to physicians.

Earl E. Lundy of Jackson is serving as first
president of the new association and other of-
ficers include Dr. Karleen C. Neill of Jackson as
president-elect, J. H. Sasser, Jr., of Carthage,
vice-president, and Normer L. Gill of Jackson,
treasurer.

Members of the board of directors are: Leslie
L. Wilkinson, L. N. Sepaugh, W. Clif Shirley,
Dr. Herbert G. Langford, Dr. Perrin H. Berry,
Dr. W. Johnson Witt, Dr. L. Tate Carl, all of Jack-
son, and Dr. W. J. Huddleston of Hattiesburg.

Jaycees Collect Drug
Samples for Vietnam

The Mississippi Jaycees have reported a suc-
cessful initial drug collection in their Jaycee In-
ternational Medical Supplies (J.I.M.S.) project
for Vietnam.

A total of 8,000 pounds of medical supplies
valued at between $40,000-50,000, was collected
from throughout the state, according to Dr. Rob-
ert L. Donald, Jr., of Pascagoula, J.I.M.S. state
chairman.

The drugs, collected from doctors’ offices, drug
company representatives, hospital medical and
surgical supplies, drug stores, and surgical sup-
ply houses, included antibiotics, vitamins, infant
formulas and food supplements, and oral contra-
ceptives.

A second J.I.M.S. drive began in April. Local
Jaycees will collect drug samples, excluding
amphetamines and barbiturates, from physicians.
Hospital administrators are asked to contribute
discarded but repairable medical and surgical
supplies.

The supplies will be shipped to Project Con-
cern, Inc., P. O. Box 2468, San Diego, Calif. This
organization, headed by Dr. James Turpin, main-
tains hospitals in Vietnam and hospital ships in
Hong Kong Harbor.

The Mississippi Air National Guard will fly the
drugs and supplies from Jaycee headquarters in
Jackson to the San Diego headquarters of Proj-
ect Concern where they will be readied for ship-
ment overseas.

282

JOURNAL MSMA

The new addition to the headquarters
building was opened with all officers and
Board members present. Upper right, Pres-
ident James L. Royals, center, wields geld
suture scissors to cut ribbon as President-
elect Paul B. Brumby, left, and Virgil
Priester, general contractor, assist. Bottom,
W. R. Bob Henry, A. I. A., architect, right,
presents keys to Building Committee, from
left, Drs. William O. Barnett, Mai S. Rid-
dell, Jr., and J. T. Davis.

WE OPEN YOUR ADDITION . . .

MAY 1970

283

VIPs GRACE THE OCCASION . . .

Association leaders, VIP's, and just
old friends — they saw the new addition
and each other. Top from left, Dr. Roy-
als greets Lt. Gov. Charles Sullivan; Miss
Louise Lacey, executive secretary of GP
Academy, chats with Dr. Ed Moak
against background of receiving line with
Dr. and Mrs. Royals and Dr. Riddell;
and Dr. William E. Lotterhos describes
new offices to Mrs. Gordon Dees (back),
Auxiliary past president. Left top, Dr.
and Mrs. Guy T. Vise inspect general
office area, and, bottom left, Dr. and
Mrs. James T. Thompson greet Dr. Louis
C. Lehmann.

284

JOURNAL MSMA

It had all the trappings of a reception
with the receiving line and silver punch
bowl. Top right. Dr. G. Swink Hicks
shows State Health Officer Hugh B. Cot-
trell around; center, Mrs. John B.
Howell, Jr., presides over punch bowl
with obvious approval of Dr. Howell;
and lower right, Mrs. William O. Barnett
talks with Dr. and Mrs. James O. Gil-
more. Bottom, the ladies like their new
office in the headquarters building, the
first permanent Woman’s Auxiliary home.
From left, Mrs. Paul B. Brumby, im-
mediate past president; Mrs. Mai S.
Riddell, Jr., past president; Mrs. Curtis
W. Caine, president-elect; and Mrs. Louis
C. Lehmann, president.

THE LADIES OPEN AN OFFICE . . .

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AMA and state association staff repre-
sentatives were on hand to see the lead-
ership. Top left, Dr. Barnett has a word
on business with AMA Field Represent-
ative Leon J. Swatzell, and center, Dr.
Howard A. Nelson looks over records
with association’s Membership Director
Cindy Sanders.

BETTER PEA CE TO DO THE JOB . . .

Allied health professions were well
represented among special guests. Lower
right, Dr. and Mrs. Everett Crawford
show Medical Care Plan Department to
Physical Therapist J. T. Gilbert.

286

JOURNAL MSMA

Heart Association
Holds Annual Meet

The Mississippi Heart Association’s 1970 An-
nual Assembly was held in Jackson April 2,
concurrently with the Mississippi Heart Associ-
ation Cardiovascular Seminar at the Univer-
sity Medical Center. The yearly event and Awards
Banquet were attended by members, volunteers
and physicians from across the state.

Elected officers for the coming year were Dr.
G. Spencer Barnes of Columbus, president; Ern-
est G. Spivey of Jackson, president-elect; Dr.
Frederick Tatum of Hattiesburg, vice-president;
Aven Whittington of Greenwood, secretary; and
Ray R. McCullen of Jackson, treasurer. Don-
ald Bartlett of Como was the outgoing president.

Keynote speaker for the meeting was Dr. Jack
W. Fleming of Pensacola, Fla., who spoke on
“Coronary Care in the Community Hospital.” Dr.

Fleming stressed the importance of the coronary
care unit, mobile coronary care unit and emer-
gency room nursing, and cited statistics to prove
that many cardiovascular disease victims can be
saved through the employment of recent medi-
cal innovations.

A panel of physicians addressed the delegates
on high blood pressure. Moderated by Dr. J. Man-
ning Hudson of Jackson, it was composed of Dr.
T. D. Lampton, assistant coordinator of the Mis-
sissippi Regional Medical Program, who dis-
cussed “The Problem in Mississippi”; Dr. Herbert
G. Langford, UMC professor of medicine, who
summarized the “Status of Knowledge”; and Dr.
John D. Wofford of Greenwood, who told “How
Heart Volunteers Can Help.”

Current programs in Cardiopulmonary Resus-
citation were cited by Dr. W. L. Wood, Jr., of
Tupelo, chairman of the CPR committee; and
in “Heart Information for the Public” by John
D. Holland of Jackson, newly elected member of
the Mississippi Heart Board of Directors.

success
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Viewing an exhibit on cardiopulmonary resusci-
tation during the Mississippi Heart Association
Annual Assembly in Jackson are newly elected of-
ficers Ernest G. Spivey of Jackson, president-elect;

Donald Bartlett of Como, outgoing president; Dr.
G. Spencer Barnes of Columbus, president; and Ray
McCullen of Jackson, treasurer.

29 1

MAY 1970

Dr. Magnuson Gets
IMA Knudsen Award

Dr. Harold j. Magnuson was accorded the
highest honor in the held of industrial medicine
when the Knudsen Award was conferred upon
him by the Industrial Medical Association, inter-
national society of physicians in industry. The
award, which was established in 1939 by the late
General William S. Knudsen, then President of
General Motors Corporation, has been presented
annually since that time in recognition of a physi-
cian who has attained distinction in the held of
occupational medicine and hygiene. A bronze
plaque, symbol of the honor, was presented to
Dr. Magnuson at the business session of the as-
sociation’s 55th annual meeting held at The Pal-
mer House.

The presentation was made by Dr. Duane L.
Block, President of the association, and Physician-
in-Charge, Rouge Medical Services, Ford Motor
Company. Dr. Block acclaimed Dr. Magnuson’s
many contributions to occupational medicine and
cited his accomplishments as an administrator,
educator and writer.

Dr. Magnuson is Associate Dean of the School
of Public Health at the University of Michigan,
Ann Arbor. Until his recent appointment as As-

sociate Dean, he was chairman of the University’s
department of industrial health and Director of
the Institute of Industrial Health. He hrst joined
the University in 1962 following his retirement
from the U. S. Public Health Service after 21
years as a Public Health Service Officer. He re-
ceived his medical degree in 1938 from the Uni-
versity of Southern California and the degree
of Master of Public Health in 1942 from the
Johns Hopkins School of Hygiene and Public
Health.

Among appointments Dr. Magnuson held with
the Public Health Service were Director of the
Venereal Disease Experimental Laboratory at
Chapel Hill, N. C., and Chief of Operational Re-
search for the PHS venereal disease program.
For the two years prior to his retirement from
the service, he was Chief of the Division of Occu-
pational Health in Washington, D. C.

Dr. Magnuson is author or co-author of nearly
100 scientific articles published in medical and
professional journals. Among his memberships, he
is a Fellow of the Industrial Medical Association,
the American College of Physicians, the Amer-
ican Public Health Association and the American
Association for the Advancement of Science. He
is a diplomate of the American Board of Pre-
ventive Medicine and a member of the Board for
occupational medicine.

—The lowest priced tetracycline— nystatin combination available—

292

JOURNAL MSMA

Wyeth Introduces
New Packaging Concept

Wyeth Laboratories has introduced a new
concept in unit dose packaging, called TUBEX®
TAMP-R-TEL®, which discourages tampering
and permits greatly improved control of inject-
able narcotics and barbiturates. TAMP-R-TEL
is a major improvement in TUBEX, Wyeth's
line of unit dose medications in pre -filled sterile
cartridge-needle units.

The new TAMP-R-TEL package will soon be
released for commercial use, and gradual turn-
over of current TUBEX narcotics and bar-
biturates into TAMP-R-TEL is expected to be
completed within the next few months.

The main features of the tamper-resistant pack-
age are transparent plastic packaging and in-
dividual cartridge slots with end-lock tabs.

According to L. J. Hymel, vice president,
sales and promotion, the TUBEX TAMP-R-TEL
concept is the result of extensive study and eval-
uation in the hospital setting. “Many hospital
personnel have stated there is pressing need for
better packaging and control of injectable nar-
cotics and barbiturates,” Hymel said. “The
TAMP-R-TEL package was specially designed
to provide such control. After months of clinical
testing and analysis of TAMP-R-TEL in a num-
ber of hospitals, we are convinced it is a major
innovation in unit dose packaging which will en-
able hospitals to significantly increase the secur-
ity of these pilferage-prone injectables.”

Key benefits of TAMP-R-TEL, Hymel says,
include the following:

— When the end-lock tab is pulled off to re-
lease medication, the manufacturer's seal is per-
manently broken. This feature enhances pack-
age integrity and discourages pilferage.

— Individual cartridge slots permit release of
a single TUBEX for unit dose dispensing. When
the end-lock tab has been broken off, special
design makes it almost impossible to replace.

— The clear plastic package permits immedi-
ate visual identification (front or back), and im-

proved control through “at-a-glance” accounta-
bility.

— Hospital personnel can be almost certain no
tampering has occurred if the end-lock tab has
not been removed.

The TAMP-R-TEL features that discourage
tampering also facilitate drug inventory count.
There are no increased storage requirements with
TAMP-R-TEL, since incorporating the new con-
cept has not changed the dimensions of the
TUBEX package.

Wyeth injectable narcotics soon to be avail-
able in TUBEX TAMP-R-TEL are codeine
phosphate, hydromorphone hydrochloride, MEP-
ERGAN®, meperidine hydrochloride, and mor-
phine sulfate.

Barbiturates in TAMP-R-TEL are pentobarbi-
tal, sodium, U.S.P.; phenobarbital, sodium, U.S.P.;
and secobarbital, sodium.

Pioneer in supplying drugs in unit dose forms,
Wyeth supplies a broad line of such medications.
Wyeth's unit dose line of injectables includes 33
drugs and 65 dosage variations in TUBEX ster-
ile cartridge-needle units. In addition, Wyeth sup-
plies an extensive selection of oral solids, liquids
and suppositories in REDIPAK® single-unit pack-
ages for hospitals.

Injectable narcotics and barbiturates in Wyeth's
new TUBEX® TAMP-R-TEL® are supplied in a
transparent plastic package with each cartridge-
needle unit locked into an individual slot within
the transparent package by its own end-lock tab.

MAY 1970

295

WMm mmm i

absor I
may su
tetrac^
I.M.
levels v
one

real broad spectrum,
including j$
susceptible strains of #.
Pneumococcus* J
“Staph"* “Strep”* f
H. influenzae* \
M. pneumoniae (PPLO)* ^
N. gonorrhoeae*

low incidence
k of diarrhea

f outstanding record
of clinical success

therapeutic blood levels
usually persisting^
around-the-clock a

Health Leaders
Met in Washington

Dr. Roger O. Egeberg, Mrs. Shirley Temple
Black, and Dr. Walter C. Bornemeier, were prin-
cipal speakers for the Third National Voluntary
Health Conference in Washington, D. C., May 7.

The two-day meeting at the Statler-Hilton Hotel
was sponsored by the Council on Voluntary
Health Agencies of the American Medical Asso-
ciation. About 400 attended the conference.

Among the other speakers were the Hon.
George Romney, secretary of Housing and Urban
Development, Dr. Julius W. Hill, president of the
National Medical Association, and Dr. Leroy
Burney, newly named executive director of the
Milbank Memorial Fund.

Dr. A. Roy Tyrer, Memphis, Tenn., chairman
of the sponsoring Council, said this was a na-
tional leadership conference to discuss all aspects
of voluntarism. The conferees explored the roles,
responsibilities, and relationships of governmental
agencies, voluntary organizations, and professional
associations, in providing health care.

The Conference theme, “Health Team Rela-
tionships: Governmental Agencies, Voluntary Or-
ganizations, Professional Associations,” was de-

veloped during the opening keynote session.

Speakers included Dr. Egeberg, assistant secre-
tary for Health and Scientific Activities of the
Dept, of HEW; Mrs. Black, member of the
Board of Trustees of the National Multiple Scle-
rosis Society; Dr. Bornemeier, president-elect of
the AMA.

Afternoon sessions featured concurrent dis-
cussion groups. Leadoff speaker at Saturday
morning’s closing session was Dr. Burney dis-
cussing the “Role of Foundations in Voluntarism.”

Continuing Professional Education Today was
discussed by Dr. David A. Wood, past chairman
of the Committee on Continuing Professional
Education Programs of Voluntary Health Agen-
cies.

Four forum sessions were given:

— Session I, Utilizing Medical Advisory Com-
mittees, Dr. Campbell Moses, medical director,
American Heart Association;

— Session II, Voluntary Health Agencies and
Regional Medical Programs, Dr. Willard A.
Wright, consultant to the AMA Committee on
Community Health Care;

— Session III, Effective Use of Volunteers and
Consumers, Dr. James E. Perkins, managing di-
rector, National Tuberculosis and Respiratory Dis-
eases Association.

HIGHLAND HOSPITAL

Asheville, North Carolina

FOUNDED 1904

A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY

Accredited by the Joint Commission on Accreditation and Certified for Medicare

Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho-
therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser-
vice work with families, family therapy and an extensive and well organized activities program, including oc-
cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The
treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may
be realized.

High school facilities for a limited number of appropriate patients are now available on grounds. The School
Program is fully integrated into the hospital treatment program and is accredited through the Asheville School
System.

Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.

Brochures and information on financial arrangements available
Contact: (1) Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions

or

(2) Samuel N. Workman, M.D. (3) Charles W. Neville, Jr., M.D.

Chief of Clinical Services Assistant Professor of Psychiatry

and Medical Director
Area Code 704-254-3201

MAY 1970

299

Can one

prescription

56th ACS Clinical
Congress to Meet

The world’s largest meeting of surgeons, the
56th annual Clinical Congress of the American
College of Surgeons, will be held in Chicago
Oct. 12-16. Some 14,000 physicians and guests
from throughout the world are expected to attend.

Headquarters hotel will be the Conrad Hil-
ton. The program will feature 1 8 postgraduate
courses, more than 260 research-in-progress re-
ports, some 60 panel discussions, operative tele-
casts from a leading Chicago hospital, and ap-
proximately 450 scientific and industrial exhib-
its.

There will be major addresses by the incoming
president of the college and selected guest speak-
ers. Convocation ceremonies for initiates becom-
ing Fellows (members) of the College will be
held Oct. 15.

The College’s Distinguished Service Award
will be presented to an outstanding Fellow of
the College and honorary fellowships will be
presented Oct. 15.

Fellows of the College whose dues are paid
to December, 1969, may register free. Non-Fel-
lows pay $90.00. Doctors in the federal services
pay $50.00. Initiates, members of the candidate
group, and surgical residents register free.

Everyone taking one of the 18 postgraduate
courses must pay the fee for the course selected.
These courses are accredited by the Council on
Medical Education of the American Medical As-
sociation.

Official registration forms will be available af-
ter June 1. For official forms contact: Mr. T. E.
McGiunis, American College of Surgeons, 55 East
Erie Street, Chicago, Illinois 6061 1.

Thoracic Society
Holds Annual Meeting

Members and guests of the Mississippi Tho-
racic Society, medical section of the Mississippi
Tuberculosis and Respiratory Disease Associa-
tion, attended the society’s 16th Annual Meeting
at the University Medical Center on Thursday,
April 16, 1970.

The scientific sessions of this one-day meeting
featured two guest lecturers, Dr. Joseph Bates,
chief of medicine, V. A. Hospital and associate

professor of medicine, University of Arkansas,
Little Rock; and Dr. John Oschner, chairman of
department of surgery, Oschner Foundation Hos-
pital and clinical associate professor, Tulane
School of Medicine, New Orleans.

Dr. Bates spoke on “Needle Biopsy for Dif-
fuse and Localized Lesions of the Lungs,” “Pneu-
monia— ‘Yesterady and Today,’ ” and “Pulmo-
nary Tularemia.” Dr. Oschner discussed “Bron-
chial Adenomas” and “Thoracic Lesions in the
Infant Requiring Urgent Surgical Care.”

Other speakers included Dr. James Hardy,
UMC, Jackson, speaking on “Current Status of
Lung Transplants”; case presentations were pre-
sented by MTS members, including Dr. Robert
Cole, Amory, Dr. Benton Hilbun, Tupelo, Dr.
John R. Williams, Greenville and Dr. Fred
Tatum, Hattiesburg.

Dr. Roland Robertson, Jackson and Dr. An-
tone Tannehill. Tupelo, co-chairmen of the pro-
gram for this meeting served as moderators for
the morning and afternoon sessions. Dr. Wilfred
Cole, MTS President, presided at the business
session-luncheon scheduled at Primos Northgate
Restaurant.

Dr. Frank Butler
Named to Committee

Dr. Lawrence W . Long of Jackson, chairman of
the MSMA Committee on Publications , welcomes
Dr. Frank L. Butler, Jr., of McComb, newly ap-
pointed committee member. The six-member com-
mittee guides the editorial policy of the Journal
and oversees production.

MAY 1970

301

ORGANIZATION / Continued

Drs. Hull, Henderson
Elected ACOG Fellows

Dr. Calvin Travis Hull of Jackson and Dr. Wil-
liam H. Henderson of Oxford will be installed
as Fellows of the American College of Obstetri-
cians and Gynecologists at its annual meeting,
April 12-18, in New York City.

The College, which was founded to promote
the health and medical care of women, accepts
physicians who specialize in obstetrics and gyne-
cology, who have demonstrated clinical ability by
successful completion of an examination, and
who have been judged by their colleagues as
competent and ethical physicians.

A Fellow must be a graduate of an approved
medical school and for at least five years prior
to applying for membership in the College, he
must have limited his practice to obstetrics and
gynecology.

Charges Dropped
Against Dr. McCaskill

Circuit Court Judge E. H. Green ordered
pending cases against Dr. Luther W. McCaskill
of Clarksdale “nolle prosequi” in a wrap-up of
the court’s activities this term.

Dr. McCaskill was charged with an alleged
illegal abortion death and with the performance
of two other alleged illegal abortions. These
charges have been dropped.

District Attorney Hoke Stone passed the phy-
sician’s capital charge as nol pros after uncover-
ing evidence which he termed “not good for the
state’s case” in Jackson recently.

County Attorney George Fleming recommend-
ed that trial for the two abortion charges be con-
tinued during the summer term of court because
“so far a diligent search has not turned up the
aborted women.”

Harvey Ross, Dr. McCaskill’s attorney, con-
tested a continuance of the charges and demand-
ed an immediate trial. Judge Green agreed that
every citizen is entitled to a speedy trial and
discharged the defendant, according to press re-
ports.

The Mississippi State Board of Health re-
stored Dr. McCaskill’s medical license on March
12, 1970, according to Dr. Hugh B. Cottrell,
Secretary, Medical Licensure.

Brief Summary of Prescribing Information-

9-9/ 22/ 69. For complete information consult
Official Package Circular.

Indications: Essential hypertension. Use cau-
tiously in patients with renal insufficiency,
particularly if they are digitalized.
Contraindications: Anuria, oliguria, active
peptic ulceration, ulcerative colitis, severe de-
pression or hypersensitivity to its components
contraindicates the use of Salutensin.
Warnings: Small-bowel lesions (obstruction,
hemorrhage, perforation and death) have
occurred during therapy with enteric-coated
formulations containing potassium, with or
without thiazides. Such potassium formula-
tions should be used with Salutensin only
when indicated and should be discontinued
immediately if abdominal pain, distension,
nausea, vomiting or gastrointestinal bleeding
occurs. Use cautiously, and only when deemed
essential, in fertile, pregnant or lactating pa-
tients. Use in Pregnancy: Thiazides cross the
placenta and can cause fetal or neonatal
hyperbilirubinemia, thrombocytopenia,
altered carbohydrate metabolism and possibly
electrolyte disturbances. Fatal reactions may
occur with reserpine during electroshock
therapy; discontinue Salutensin 2 weeks be-
fore such therapy. Increased respiratory
secretions, nasal congestion, cyanosis and
anorexia may occur in infants born to reser-
pine-treated mothers.

Precautions: Azotemia, hypochloremia, hypo-
natremia, hypochloremic alkalosis and hypo-
kaliemia (especially with hepatic cirrhosis
and corticosteroid therapy) may occur, par-
ticularly with pre-existing vomiting and diar-
rhea. Potassium loss or protoveratrine A may
cause digitalis intoxication. Potassium loss
responds to potassium-rich foods, potassium
chloride or, if necessary, discontinuation of
therapy. Stop therapy if protoveratrine A
induces digitalis intoxication. Serum am-
monia elevation may precipitate coma in
precomatose hepatic cirrhotics. Discontinue
therapy 2 weeks before surgery or if myo-
cardial irritability, progressive azotemia or
severe depression occur. Exercise caution in
patients with chronic uremia, angina pec-
toris, coronary thrombosis or extensive cere-
bral vascular disease or bronchial asthma and
in those with a history of peptic ulceration or
bronchial asthma; in post-sympathectomy pa-
tients; in patients on quinidine; and in pa-
tients with gallstones, in whom biliary colic
may occur. Patients who have diabetes
mellitus or who are suspected of being pre-
diabetic should be kept under close observa-
tion if treated with this agent.

Adverse Reactions: Hydroflumethiazide: Skin
rashes (including exfoliative dermatitis), skin
photosensitivity, urticaria, necrotizing angiitis,
xanthopsia, granulocytopenia, aplastic
anemia, orthostatic hypotension (potentiated
with alcohol, barbiturates or narcotics), aller-
gic glomerulonephritis, acute pancreatitis,
liver involvement (intrahepatic cholestatic
jaundice), purpura plus or minus throm-
bocytopenia, hyperuricemia, hyperglycemia,
glycosuria, malaise, weakness, dizziness, fa-
tigue, paresthesias, muscle cramps, skin rash,
epigastric distress, vomiting, diarrhea and
constipation. Reserpine: Depression, peptic
ulceration, diarrhea, Parkinsonism, nasal stuf-
finess, dryness of the mouth, weight gain,
impotence or decreased libido, conjunctival
injection, dull sensorium, deafness, glaucoma,
uveitis, optic atrophy, and, with overdosage,
agitation, insomnia and nightmares. Proto-
veratrine A: Nausea, vomiting, cardiac ar-
rhythmia, prostration, blurring vision, mental
confusion, excessive hypotension and brady-
cardia. (Treat bradycardia with atropine and
hypotension with vasopressors.)

Usual Dose: 1 tablet b.i.d.

Supplied: Bottles of 60, 600, and 1000 scored
50 mg. tablets.

Salutensin9

hydroflumethiazide, 50 mg./reserpine,
0.125 mg. protoveratrine A, 0.2 mg.

BRISTOL

BRISTOL LABORATORIES
Division of Bristol-Myers Company
Syracuse, New York 13201

fhe anti hypertensive therapy
that is easy to live with.

When successive blood pressure readings confirm
issential hypertension, consider Salutensin for:
£asy-to-live-with control. Gradual reduction of
Dlood pressure leading to decisive, comfortable
;ontrol is the common clinical response.

Salutensin is usually well-tolerated (however,
;erious side effects can occur; see adjacent column
:or brief summary of prescribing information).

Easy-to-Iive with dosage. Two tablets a day
usually achieves control. One to two tablets a day
often maintains control without need for additional
antihypertensive agents.

JEasy-to-Uve with cost of therapy. The one to two
tablets a day maintenance dose makes Salutensin
economical to stay with. Important, because long-
term control calls for long-term therapy.

Salutensin

umethiazide,50 mg./reserpine,
g. protoveratrine A, 0.2 mg.

UMC Commencement
Activities Announced

The Honorable James P. Coleman, former
governor of Mississippi, will give the graduation
address at the 14th Commencement of the Uni-
versity of Mississippi at the Medical Center on
Sunday, June 7, at 4:00 p.m. in the Jackson
City Auditorium.

Chancellor of the University of Mississippi Dr.
Porter L. Fortune will award degrees to candi-
dates from the School of Medicine, the School of
Nursing and the Graduate School. This year
candidates from the School of Medicine num-
ber 75.

Recipients of the Leathers Medal and Facul-
ty Award, highest recognition offered by the
medical and nursing schools, will be announced
during the ceremony.

Commencement activities will begin with a
breakfast for the graduates and their families on
Sunday. At 2:00 p.m. Chancellor and Mrs. For-
tune will entertain at a reception honoring gradu-
ates, their families and friends in the School of
Nursing Auditorium.

Dr. Charles Tate
Addresses TB-RD Ass’n.

Dr. Charles F. Tate, Jr., associate professor
of medicine, University of Miami School of Medi-
cine, was guest speaker at the 58th Annual Meet-
ing of the Mississippi Tuberculosis and Respira-
tory Disease Association in Jackson at Primos
Northgate Convention Center on April 15,
1970.

Dr. Tate presented a paper on “The Hazards
of Smoking — Kick the Habit.” Dr. Tate is an ac-
tive volunteer board member of the Dade-Mon-
roe County and the Florida TB-RD Associa-
tions and a Counselor-at-Large of the American
Thoracic Society.

Representative delegates of the more than 4,000
volunteers, including laymen and physicians, of
the Mississippi Tuberculosis and Respiratory Dis-
ease Association assembled for this luncheon-
business meeting.

The theme of the MTRDA Annual Meeting
was “Kick the Habit.” An extensive nationwide
educational-public information project, sponsored
by TB-RD Associations will be conducted in June
1970. The MTRDA and its 87 affiliated volun-
teer county associations will participate in the
“Kick the Habit” educational project.

304

Dr. Hardy Awarded I
ACC Fellowship

A Mississippi physician has been granted a
Fellowship in the American College of Cardiolo-
gy (ACC), the national medical society for spe-
cialists in cardiovascular diseases. The doctor is
among a group of 181 from the United States
and Canada recently admitted to the College’s
highest membership classification.

Dr. Harper K. Hellems, Jackson, ACC Gover-
nor for Mississippi, listed the new Fellow as Dr.
James D. Hardy, Jackson.

Dr. Hardy, as well as the other new Fellows,
has fulfilled stringent membership requirements
based on several years of practice and specialty
certification. This effort, according to Dr. Hel-
lems, culminates in their being considered by
colleagues in their communities as specialists or
consultants in cardiovascular diseases.

Governor Signs MSMA
Corporation Law

Gov. John Bell Williams signs the state medical
association’ s professional corporation bill into law
as President James L. Royals observes . Bill became
law in March and makes professional corporations,
with all benefits of commercial corporations, available
to Mississippi physicians.

JOURNAL MSMA

Burdick

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Write us for descriptive literature and com-
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ARCH LABORATORIES

319 South Fourth Street. St. Louis, Missouri 63102

Index to Advertisers

Arch Laboratories 307

Blue Cross, Blue Shield 14

Breon Laboratories 8

Bristol Laboratories 302, 303

Burroughs-Wellcome 14B

Campbell Soup Company 272A

Conal Pharmaceuticals 280A

Dow Chemical Company 14A

Flint Laboratories 10, 11

Geigy Pharmaceuticals 14D, 15

Highland Hospital 299

Hill Crest Hospital 6

Hoechst Pharmaceuticals 12

Hynson. Westcott & Dunning 3

Kay Surgical 307

Lederle Laboratories 4, 287, 292, 306

Eli Lilly and Company front cover, 18

Merck, Sharp and Dohme 288, 289. 290

William S. Merrell Company 300

National Drug Company second cover, 300A, 300B

Chas. Pfizer & Co., Inc 296, 297. 298

Wm. P, Poythress 14C, 272D

Roche Laboratories 7, 305, fourth cover

Julius Schmid, Inc 16, 17

G. D. Searle Co 272B, 272C

Stuart Pharmaceuticals, Division of Atlas

Chemical Industries, Inc 280B

Wyeth Laboratories 293, 294

Thomas Yates and Company third cover

MAY 1970

307

102nd iinnual oession, a little more than a week away, opens May 11
at Biloxi with something for everybody* Outstanding essayists are
on program, biggest scientific exhibit yet will be presented, a doze
specialty societies will meet, and four medical alumni social oc-
casions are in offing. University of Tennessee, late getting arrant
ments finalized, plans gala iuesday evening, May 12. Ole Miss is or
Monday, while Tulane and Vanderbilt have Tuesday evening parties.

Shortage of nursing home beds in Mississippi is easing up, according
to State Board of Health which licenses institutions. Generally ac-
cepted formula is 40 beds per 1,000 persons over-65, meaning state
should have 8,550 beds. Present total is 6,000 beds and is rapidly
expanding with new construction on existing homes, projects nearing
completion, and plans on drawing boards. Forecast is for 8,500 beds
in a year. State licenses 112 institutions at present.

■

Household detergents are getting eye from pollution-conscious source
with allegation that they are drug-like products marketed before suf
ficient testing. Charge is that some detergent products contain
phosphates with arsenic as a constant impurity, as much as 25 ppm.
Arsenic in waste water from washing machines has been found to range
5 to 100 ppb, and recent tests showed water in Kansas River tested
2 to 8 ppb of arsenic.

Alabama M.D. »s are gnashing teeth over backlog of 120,000 unpaid Med-
care claims. State medical society reports that similar backlog of
38 , 000 pending Medicaid claims are being processed. Reports are tha
Alabama Blue plan, which is fiscal administrator for both programs,
bogged down in computer processing. Mississippi Medicaid program,
just four months old, has also had data processing problems but is
said to be catching up and moving toward current payment basis.

National Institute of Mental Health will soon offer formal training
programs in prevention of suicide, now the 10th leading cause of deal
in U.S. A full year interdisciplinary fellowship in suicidology be-
gins in September and carries "stipends up to $l2,600. Ten weeks in-
struction program requires no doctoral degree and has stipends up to
$2,400 . Two-week summer institute in suicidology will also be con-
ducted for prevention center workers, police, clergy, and others.

Volume XI
Number 6
June 1970

• EDITOR

[William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.

Thomas W. Wesson, M.D.

i

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL CONSULTANT
Betty M. Sadler

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.
Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary-T reasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

original papers

Pacemaker Management of

Heart Block 309 John W. Bowlin, M.D.

Artificial Kidneys in Acute

Renal Failure 317 John D. Bower, M.D.

Potassium Therapy and

Gastrointestinal Lesions 321 David N. Emerson, Ph.D.

SPECIAL ARTICLES

Recent Advances in

Newborn Care 327 Alfred W. Brann, Jr.,

M.D.

Radiologic Seminar
XCVI: Reversible
Vascular Occlusion of the

Colon 331 C. D. Bouchillon, M.D.

EDITORIALS

Abortion and the Law:

Anachronisms Racing

Science 335 It’s Up to the Court

The CBS Eye:

Color It Yellow 336 Video Jaundice
Goods and Services

Simply Cost More 337 Curve Goes up. Up, UP!

THIS MONTH

The President Speaking 334 ‘Changes and Challenge’

Medical Organization 343 The 102nd Annual Session

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR JUNE 1970

human disease. Thus medicine opposes chiroprac-
tic for the same reason it opposes other forms of
health quackery: to try to prohibit poorly-trained
individuals from performing functions for which
they are totally unqualified.

Significant developments from outside medi-
cine have occurred in regard to chiropractic dur-
ing the past year.

The U. S. Department of Health, Education and
Welfare submitted findings of an independent,
unbiased study of chiropractic ordered by Con-
gress. In a report to Congress in January 1969
by Wilbur J. Cohen, then secretary of HEW, it
was recommended that chiropractic service not
be covered in the medicare program.

The report, considered to be the most pene-
trating analysis of chiropractic ever made, con-
cluded: “Chiropractic theory and practice are
not based upon the body of basic knowledge re-
lated to health, disease, and health care that has
been widely accepted by the scientific commu-
nity. Moreover, irrespective of its theory, the
scope and quality of chiropractic education do
not prepare the practitioner to make an ade-
quate diagnosis and provide appropriate treat-
ment.”

HEW told Congress that its study, after evi-
dence had been presented by chiropractic’s fore-
most spokesmen, educators and practitioners,
showed, among other things, that:

—The lowest priced tetracycline— nystatin combination available—

HEW, AFL-CIO Are
Against Chiropractic

Medicine and other branches of the scientific
community have insisted for the past 75 years
that chiropractic is an unscientific cult, whose
practitioners are not qualified to diagnose and
treat human disease.

Chiropractic, in turn, has claimed that medi-
cine’s opposition is for selfish reasons only. “The
citizen has the obligation to take a firm stand
against the monopolistic goals of the American
Medical Association,” states a booklet distribut-
ed by the American Chiropractic Association.

Until the past year, the medical profession
virtually alone assumed the responsibility of in-
forming the public about the invalidity of the
chiropractic hypothesis (that human disease is
caused by a spinal subluxation and cured by a
spinal adjustment). Chiropractic shortcomings in
education and practice were set forth.

Medicine’s position is that all methods of dis-
ease prevention, health maintenance and care
should be submitted to careful scrutiny and ob-
jective evaluation — the scientific process. Despite
being 75 years old, chiropractic has failed to
produce any scientific proof for its theories, while
claiming competence to treat the broad gamut of

MISSISSIPPI STATE MEDICAL ASSOCIATION

7

1. There is a body of basic scientific knowl-
edge related to health, disease, and health
care. Chiropractic practitioners ignore or take
exception to much of this knowledge despite
the fact that they have not undertaken ade-
quate scientific research.

2. There is no valid evidence that subluxa-
tion, if it exists, is a significant factor in dis-
ease processes. Therefore, the broad applica-
tion to health care of a diagnostic procedure
such as spinal analysis and a treatment pro-
cedure such as spinal adjustment is not justi-
fied.

3. The inadequacies of chiropractic educa-
tion, coupled with a theory that de-emphasizes
proven causative factors in disease processes,
proven methods of treatment, and differential
diagnosis, make it unlikely that a chiropractor
can make an adequate diagnosis and know the
appropriate treatment, and subsequently pro-
vide the indicated treatment or refer the pa-
tient. Lack of these capabilities in independent
practitioners is undesirable because appropri-
ate treatment could be delayed or prevented
entirely; appropriate treatment might be in-
terrupted or stopped completely; the treatment
offered could be contraindicated; all treatments
have some risk involved with their adminis-
tration, and inappropriate treatment exposes
the patient to this risk unnecessarily.”

Other organizations outside medicine have
spoken publicly with resolutions or statements in
opposition to chiropractic. Some statements
have come from organizations such as the AFL-
CIO and National Council of Senior Citizens,
which in the past have not been on the same
side of the fence as the American Medical Asso-
ciation in regard to federal health care matters.

Where it became a matter of providing quality
health care to the elderly, as required by the
medicare law, the organizations opposed chiro-
practic inclusion. As the National Council of Sen-
ior Citizens emphasized. “With chiropractic and
other completely unscientific cults, there is no
possibility for quality health care.”

The AFL-CIO Executive Council recently is-
sued a statement that said, in part:

“Of equal importance to holding down costs
is the maintenance of quality care in the medi-
care program. Of immediate concern is the threat
to quality care represented by the drive to in-
clude less than fully qualified medical practition-
ers such as chiropractors in the medicare pro-
gram. At stake is the direct access to the billions
of dollars for health care being provided the
elderly by the medicare program. Medicare

should not become a vehicle for exploitation of
the health needs of the elderly. The AFL-CIO
opposes any change in the medicare law which
would open up the program to unqualified prac-
titioners.”

The National Council of Senior Citizens, an
organization composed of 2Vi million persons 65
years of age or older (the medicare recipients
themselves), stated its views in its official news-
paper, the Senior Citizens News, in January
1969. The article entitled “Why Chiropractic
Cult Cannot Provide Quality Health Care!” in-
cluded the conclusion:

“Chiropractic treatment, designed to eliminate
causes that do not exist while denying the exis-
tence of the real causes, is at best worthless —
and at worst mortally dangerous.”

The American Public Health Association, com-
posed of administrators of the nation’s public
health programs, spoke out at its annual meeting
in November 1969. The APHA’s governing coun-
cil endorsed the HEW report and urged con-
tinued exclusion of chiropractic from medicare.

In addition, the APHA urged “that States re-
evaluate their existing licensure programs for
chiropractors and naturopaths to determine
whether such licenses should be further restrict-
ed or abolished, and that existing licensure pro-
grams be more rigorously policed.” The APHA
resolution also recommended “that professional
and consumer groups undertake appropriate con-
sumer education on the hazards of unscientific
health care, including chiropractic or naturopa-
thy.”

Continued exclusion of chiropractic under
medicare was supported also by a blue ribbon
task force appointed by HEW Secretary Robert
H. Finch to study the problems of medicaid
and related programs. Under medicaid (Title
XIX of the Social Security Act) programs are
state-administered with financial assistance from
federal funds. Some states have authorized pay-
ment for chiropractic services under medicaid.
The HEW task force reported in November 1969.
It concluded that payment for chiropractic and
naturopathic services “is not an effective use of
federal medicaid funds.”

The task force report urged, “A legislative
amendment should be enacted denying federal
financial participation in medicaid payments to
chiropractors and naturopaths.”

One of the principal drives by chiropractic
in state legislatures in recent years is for passage
of so-called insurance equality laws that would
make inclusion of payment for chiropractic ser-
vices mandatory in all health insurance policies.

The pain
of arthritis

relieved with

MEASURIN q. 8h. dosage

Double-strength Measurin timed-release aspirin offers a new

kind of control for your arthritic patients. Each 10-grain tablet

has over 6,000 microscopic reservoirs that release

aspirin at a controlled rate— some right away and some

later on. This means— fast relief, followed by long

lasting relief. Throughout the day, Measurin

gives your patients freedom from a 4-hour dosage

schedule. Measurin can help your patients get

a good night’s sleep, uninterrupted by the need for

an extra dose of aspirin. And, taken at

bedtime, it also helps ease morning joint

discomfort and stiffness.

For Professional Samples write:
Breon Laboratories Inc.

Sample Fulfillment Division
P.0. Box 141
Fairview, NJ. 07022

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90 Park Avenue, New York, N.Y. 10016
Subsidiary of Sterling Drug Inc.

Measurin

TIMED-RELEASE ASPIRIN

ECONOMICAL • EFFECTIVE • LONG LASTING PAIN RELIEF
Dosage: 2 tablets followed by 1 or 2 tablets every
8 hours as required, not to exceed 6 tablets in 24 hours.
For maximum nighttime pain relief and to help relieve
early morning stiffness, 2 tablets at bedtime.

Available: Bottles of 12, 36 and 60 tablets.

^

*>r Doctor:

June 1970

egress is putting the dollar crunch on Medicare and Medicaid with
i amendments which breezed through, the House of Represen tatives~
Si care beneficiaries may now choose to be under closed panel plans
fc ch would receive on capitation basis up to 95 per cent of what
cld be paid under fee-for-service. Law would also place ceiling
nM.D. fees at 75th percentile of 1969 levels.

New bill would repeal controversial Medicaid escalation
clause requiring comprehensive programs for all by 1^7'/.
Usual election year lagniappe of 5 per cent Social Se-
curity payment increase - with bigger taxes - was passed.
Chiropractic was again excluded from Medicare.

jt June 21-25 Chicago annual convention will be a corker with hot
E lilies, emotion- charged issues, and biggest money problems yet,
legates will be asked to raise aMa lues to $150 per year for new
E.dership programs, back income taxes due on JAMA, needed reserves,
n. cos t-of- inflation upsurges. Himler Report will dominate debate,
l; liberalization of abortion policy to patient-physician decision
Er stir most discussion.

1? medical students in Jackson gave President Nixon *s Cambodia
Etpaign overwhelming support, as shown in recent opinion poll.1

Iident body voted 69 per cent to support cleaning out Viet Cong
ictuaries across border, while 28 per cent opposed and 3 per
it had no opinion. Mass news media have largely portrayed medi-
students as being in forefront of peace-now, get-out moves.

;t pessimistic prediction yet on hospital costs comes from former
r health chief and president of the American Hospital Association.
:lres sing recent San Rran cisco meeting, t)r. Philip R. Lee and Mark
I'ke said that by 1980, hospital costs in some parts of U.S. could
to $1,000 per day. Inference is that levels of a third to a half
that figure may be commonplace.

isrican Cancer Society was embarrassed when its prize TV antismoking
Lebrity, Tony Curtis, was convicted for marijuana possession. Cur-
5, who received heavy TV exposure in ACS anti tobacco commercials ,
ioarently has different feelings about pot than on fags. Blow to
ijiety comes on heels of public rift with Tobacco Institute over
Lidity of smoking-dog lung cancer research.

THE JOURNAL FOR JUNE 1970

1 0

Rocky Mt. Cancer
Conference to Meet

The historic Brown Palace Hotel in Denver
will be the site of the 24th Annual Rocky Moun-
tain Cancer Conference. The Conference, to take
place on July 17 and 18, 1970, is expected to
attract over 400 physicians from all over the
country. It has earned the reputation of being
one of the finest medical meetings of its kind in
the country.

This year the guest faculty will discuss G.I.
tract tumors and soft tissue cancers. President-
elect of the American Medical Association, Dr.
Walter C. Bornemeier, Chicago, will be the lunch-
eon speaker on Saturday. Luncheon speaker on
Friday will be Dr. Jonathan E. Rhoads, chair-
man of the department of surgery at the Univer-
sity of Pennsylvania and president of the Amer-
ican Cancer Society.

These distinguished gentlemen will be joined

by an equally distinguished faculty. Each physi-
cian will present a paper and in addition will
take part in panel sessions. Scientific presenta-
tions will include “Malignant Melanomas,” “Re-
sults of Radiation Therapy Augmented by 5-Flu-
ouracil or Oxygen in the Treatment of Gastroin-
testinal Malignancies,” “Host Defense Mecha-
nisms in Malignant Melanoma,” “What Is Being
Done About Colon Cancer?,” and “Management
of Soft Tissue Sarcomas.”

Local Colorado physicians, with national repu-
tations, will moderate the panel sessions. They
include: Drs. Alexis E. Lubchenco, Frank B.
McGlone, and Mason Morfit, all of Denver.

Conferees will stay at the Brown Palace Hotel
and many will extend their stay in Colorado to
visit the scenic, cool vacationland. The combina-
tion of a thought-provoking scientific meeting and
a trip to the mountains will attract many physi-
cians and their wives. Details can be obtained
by writing to the Rocky Mountain Cancer Con-
ference, 1764 Gilpin Street, Denver, Colo. 82018.

HIGHLAND HOSPITAL

Asheville, North Carolina

FOUNDED 1904

A DIVISION OF THE DEPARTMENT OF PSYCHIATRY OF DUKE UNIVERSITY

Accredited by the Joint Commission on Accreditation and Certified for Medicare

Complete facilities for evaluation and intensive treatment of psychiatric patients, including individual psycho-
therapy, group therapy, psychodrama, electro-convulsive therapy, Indoklon convulsive therapy, drugs, social ser-
vice work with families, family therapy and an extensive and well organized activities program, including oc-
cupational therapy, art therapy, music therapy, athletic activities and games, recreational activities and outings. The
treatment program of each patient is carefully supervised in order that the therapeutic needs of each patient may
be realized.

High school facilities for a limited number of appropriate patients are now available on grounds. The School
Program is fully integrated into the hospital treatment program and is accredited through the Asheville School
System.

Complete modern facilities with 85 acres of landscaped and wooded grounds in the City of Asheville.

Brochures and information on financial arrangements available
Contact: (1) Mrs. Elizabeth Harkins, ACSW, Coordinator of Admissions

or

(2) Samuel N. Workman, M.D. (3) Charles W. Neville, Jr., M.D.

Chief of Clinical Services Assistant Professor of Psychiatry

and Medical Director
Area Code 704-254-3201

,00 Americans New York - More than 3,000 American students

:k M.D. Abroad are in foreign medical schools, but the easy

solution of going abroad for M.D. training will
tougher. Biggest group of Americans in foreign schools are in
ly where 1,000 are enrolled, and Mexico is next with 600. Schools
Switzerland, where most foreign trained Americans have attended,
closing doors to U.S. applicants in favor of helping poor, not
;h, nations. Restrictions are also seen in Netherlands and Spain.

J Opens Blood Jackson - The University of Mississippi School
>curement Office of Medicine is enjoying success in finding new

supplies of human blood with its Blood Procure-
it Office. When facility was first opened, blood replacement ran
>ut 55 per cent. Recently, replacement was 100 per cent for a full
ith. Effort is reducing costs, too, because UMC now purchases only
) to 200 units per month against former 600. Numerous open heart
?gical procedures at UMC intensify blood needs.

liologists Get Chicago - While the vast majority of American
ial Fee Assurance physicians fret and fume over Medicare fees,

the American College of Radiology has come up
bh the nearest thing to true usual and customary fees in agree-
it with Social Security Administration. Radiologists who bill
i-Medicare patients for a period of a year may have these fees
cognized as usual, customary, and reasonable for Medicare. The
?eement was formalized in SSA instructions to carriers.

bem, Resident Boston - The authoritative New England Journal

flighting Hit of Medicine has raised serious questions about

interns and residents moonlighting, such as
ikend emergency coverage, insurance examinations, and making
?sing home visits. Journal says that inexperience could lead to
Lficult medicolegal situations, that work can interfere with the
lining program, and that lack of rest and relaxation may make
5k a dull intern or resident.

5 Opens Capitol Washington - The American Academy of Pediatrics
LI Office has joined the growing number of specialty soci-

eties to open Washington offices. Plans call
? July 1 opening of AAP Capitol Hill office "to identify the AAP
the primary professional health organization concerned with matters
child health. " Previously, the College of American Pathologists
1 American College of Radiology have opened Washington offices.

THE JOURNAL FOR JUNE 1970

1 4

Blood Donor Month
Increased Supply

Celebration of January for the first time as
National Blood Donor Month increased the post-
holiday blood supply importantly at the time of
greatest seasonal need, the American Association
of Blood Banks has reported to President Nixon
who proclaimed the month.

“The almost nationwide shortages of 1969
and 1968 at this time were not repeated,” said
Dr. Enold H. Dahlquist, Jr., of Providence, R. I.,
association president. “There were very few re-
ports of surgery being delayed for lack of blood.
Such reports were numerous last year.

“Many blood banks reported an increase in
donors in January 1970, over January 1969, some
as high as 25 per cent. A large number of people
gave for the first time. This is especially encourag-
ing. When a person gives once, he discovers his
fears to be groundless and he is happy to become
a regular donor. Blood is needed every day of
the year.

“Where local shortages became critical in Jan-

uary, donors responded to emergency press and
radio-television appeals. All concerned are grate-
ful to the news media for this cooperation as well
as to Congress and President Nixon for establish-
ing January as National Blood Donor Month.”

President Nixon on Dec. 31 proclaimed this
“to pay special tribute to the voluntary blood
donor and to encourage increasing numbers of
people to be voluntary blood donors” saying no
gift is “more priceless in time of personal crisis,
than the donation of one’s blood” and “the vol-
untary blood donor truly gives life itself.”

“Mobilized through the American Red Cross
and the American Association of Blood Banks,
and encouraged by modern medical techniques,”
said President Nixon “. . . the ranks of the vol-
untary blood donor have continued to grow and
to make unparalleled contributions to the health
of our people.”

Saying it was in response to the President’s
proclamation, the Dads Club of St. Thomas
Aquinas School in Dallas donated 24 pints to
the Wadley Blood Bank. This had 500 more Jan-
uary donors than in 1969, an increase of 20 per
cent. Increases also were reported at Beaumont
and Austin, Tex., and Ardmore, Okla.

HOSPITAL

(Formerly Hill Crest Sanitarium)

7000 5TH AVENUE SOUTH
Box 2896, Wood! awn Station
Birmingham, Alabama 35212

Phone: 205-836-7201

A patient centered
independent hospital for
intensive treatment of
nervous disorders . . „

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 44 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James A. Becton, M.D., F.A.P.A.

CLINICAL DIRECTORS:

James K. Ward, M.D., F.A.P.A.
Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation ol Hospitals
and is also approved for Medicare pa-
tients.

Cfte st

HOSPITAL

BIRMINGHAM, ALABAMA

for the debilitated
geriatric patient

TABLETS

high potency B-complex and C
for nutritional support

AVAILABLE ONLY ON Rx
contains water-soluble vitamins only
b.i.d. dosage
good patient acceptance
no odor, and virtually no aftertaste

Each Berocca Tablet contains:

Thiamine mononitrate 15 mg

Riboflavin 15 mg

Pyridoxine HCI 5 mg

Niacinamide 100 mg

Calcium pantothenate 20 mg

Cyanocobalamin 5 meg

Folic acid 0.5 mg

Ascorbic acid 500 mg

Usual dosage is one tablet b.i.d.

Indications: Nutritional supplementation in conditions in
which water-soluble vitamins are required prophylactically
or therapeutically.

Warning: Not intended for treatment of pernicious anemia
or other primary or secondary anemias. Neurologic involve-
ment may develop or progress, despite temporary remission
of anemia, in patients with pernicious anemia who receive
more than 0.1 mg of folic acid per day and who are in-
adequately treated with vitamin B]2.

Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

Roche

LABORATORIES

Division of Hoffmann-La Roche Inc.
Nutley, New Jersey 07110

3-D X-Ray Film
System Developed

Photosystems Corporation, a Long Island com-
pany specializing in advanced photo-optical en-
gineering, has announced that it has completed
the development of a system for producing three-
dimensional x-ray films. The equipment has been
delivered to Albert Einstein College of Medicine,
Bronx, New York for clinical evaluation.

Richard A. Hayes, president of Photosystems
Corporation, indicated that the new x-ray system
is the result of a three-year research and de-
velopment effort by a team of company scientists
and engineers, with medical direction by Dr.
Reuben Hoppenstein, a neurosurgeon. Before be-
ing released for medical evaluation, said Hayes,
the equipment was subjected to exhaustive en-
gineering tests over a period of six months.

The new apparatus, known as the “Tridex”
Three-Dimensional Time Sequence Radiograph,
is used in conjunction with standard hospital
x-ray equipment, and produces a three-dimen-
sional radiogram on a single sheet of conventional
medical x-ray film. The system includes an il-
luminated viewer for displaying the three-dimen-
sional x-ray, which is viewed with the unaided
eye. There is no requirement for special eye-
glasses.

The new Photosystems equipment will also
produce a time sequence of several consecutive
x-rays on a single sheet of film, and display them
in animated form. The animation can be speeded
up, slowed down, or stopped at any point, by
adjusting the viewer controls.

The company indicated that its three-dimen-
sional x-ray system is designed to operate at ap-
proximately the same levels of patient radiation
as used in conventional radiological techniques
of the type requiring multiple exposure. In some
of these procedures, it is anticipated that the new
system will require a lesser number of individual
exposures, and thereby permit a decrease in total
radiation.

Clinical evaluation at Albert Einstein College
of Medicine will be under the director of Dr.
Mannie M. Schechter, professor of radiology.

Brief Summary of Prescribing Information-

9-9/ 22/ 69. For complete information consult
Official Package Circular.

Indications: Essential hypertension. Use cau-
tiously in patients with renal insufficiency,
particularly if they are digitalized.
Contraindications: Anuria, oliguria, active
peptic ulceration, ulcerative colitis, severe de-
pression or hypersensitivity to its components
contraindicates the use of Salutensin.
Warnings: Small-bowel lesions (obstruction,
hemorrhage, perforation and death) have
occurred during therapy with enteric-coated
formulations containing potassium, with or
without thiazides. Such potassium formula-
tions should be used with Salutensin only
when indicated and should be discontinued
immediately if abdominal pain, distension,
nausea, vomiting or gastrointestinal bleeding
occurs. Use cautiously, and only when deemed
essential, in fertile, pregnant or lactating pa-
tients. Use in Pregnancy: Thiazides cross the
placenta and can cause fetal or neonatal
hyperbilirubinemia, thrombocytopenia,
altered carbohydrate metabolism and possibly
electrolyte disturbances. Fatal reactions may
occur with reserpine during electroshock
therapy; discontinue Salutensin 2 weeks be-
fore such therapy. Increased respiratory
secretions, nasal congestion, cyanosis and
anorexia may occur in infants born to reser-
pine-treated mothers.

Precautions: Azotemia, hypochloremia, hypo-
natremia, hypochloremic alkalosis and hypo-
kaliemia (especially with hepatic cirrhosis
and corticosteroid therapy) may occur, par-
ticularly with pre-existing vomiting and diar-
rhea. Potassium loss or protoveratrine A may
cause digitalis intoxication. Potassium loss
responds to potassium-rich foods, potassium
chloride or, if necessary, discontinuation of
therapy. Stop therapy if protoveratrine A
induces digitalis intoxication. Serum am-
monia elevation may precipitate coma in
precomatose hepatic cirrhotics. Discontinue
therapy 2 weeks before surgery or if myo-
cardial irritability, progressive azotemia or
severe depression occur. Exercise caution in
patients with chronic uremia, angina pec-
toris, coronary thrombosis or extensive cere-
bral vascular disease or bronchial asthma and
in those with a history of peptic ulceration or
bronchial asthma; in post-sympathectomy pa-
tients; in patients on quinidine; and in pa-
tients with gallstones, in whom biliary colic
may occur. Patients who have diabetes
mellitus or who are suspected of being pre-
diabetic should be kept under close observa-
tion if treated with this agent.

Adverse Reactions: Hydroflumethiazide: Skin
rashes (including exfoliative dermatitis), skin
photosensitivity, urticaria, necrotizing angiitis,
xanthopsia, granulocytopenia, aplastic
anemia, orthostatic hypotension (potentiated
with alcohol, barbiturates or narcotics), aller-
gic glomerulonephritis, acute pancreatitis,
liver involvement (intrahepatic cholestatic
jaundice), purpura plus or minus throm-
bocytopenia, hyperuricemia, hyperglycemia,
glycosuria, malaise, weakness, dizziness, fa-
tigue, paresthesias, muscle cramps, skin rash,
epigastric distress, vomiting, diarrhea and
constipation. Reserpine: Depression, peptic
ulceration, diarrhea, Parkinsonism, nasal stuf-
finess, dryness of the mouth, weight gain,
impotence or decreased libido, conjunctival
injection, dull sensorium, deafness, glaucoma,
uveitis, optic atrophy, and, with overdosage,
agitation, insomnia and nightmares. Proto-
veratrine A: Nausea, vomiting, cardiac ar-
rhythmia, prostration, blurring vision, mental
confusion, excessive hypotension and brady-
cardia. (Treat bradycardia with atropine and
hypotension with vasopressors.)

Usual Dose: 1 tablet b.i.d.

Supplied: Bottles of 60, 600, and 1000 scored
50 mg. tablets.

Salutensin

hydroflumethiazide, 50 mg. /reserpine,

0.125 mg. protoveratrine A, 0.2 mg.

BRISTOL LABORATORIES
Division of Bristol-Myers Company
Syracuse, New York 13201

BRISTOL

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

June 1970, Vol. XI, No. 6

Pacemaker Management

Of Heart Block

JOHN W. BOWLIN, M.D.

Tupelo, Mississippi

Within the last decade the advent and re-
finement of electrical cardiac pacing has greatly
improved the prognosis in patients suffering from
chronic heart block and Stokes-Adams attacks.
This report discusses the temporary and perma-
nent applications of pacemaker systems in heart
block and cardiac arrhythmias and summarizes
experience with cardiac pacemaker implantations
at the North Mississippi Medical Center during
the last two years.

Gould,1 in 1929, first successfully restored a
heart beat with electricity by inserting an elec-
trode needle percutaneously into the myocardi-
um. Zoll,2 in 1952, successfully resuscitated a
heart in ventricular standstill by use of an ex-
ternal pacemaker. These early methods of shock-
ing, defibrillating, and pacing the heart were
mainly applied to patients undergoing cardiac
surgery which was then, too, in its infancy.

Later, when Weirich, Lillehei and associates3
reported in 1957 the use of myocardial electrodes
connected to an external pacemaker, the poten-
tial application of similar systems to patients
with chronic heart blocks and Stokes-Adams at-
tacks was realized. This type of external pacing

Read before the 101st Annual Session, Mississippi State

Medical Association, Biloxi, May 14, 1969.

system was utilized in some patients with sig-
nificant advancement; however, infection arising

Mortality and morbidity of heart block
and Stokes-Adams attacks has been greatly
altered during the past decade with the de-
velopment of reliable permanent pacing sys-
tems. Use of the different pacemaker sys-
tems is reviewed and experience with cardi-
ac pacemaker implantations at North Mis-
sissippi Medical Center during the last two
years is reported.

from externally placed electrodes resulted in fre-
quent failure. This problem was solved in 1961
when Chardack1 reported his use of a totally
self-contained permanent pacemaker system,
with placement of myocardial electrodes at thora-
cotomy connected to a subcutaneously placed
pulse generator. This continuing progress, com-
bining the achievements of cardiology, surgery,
electronics and biophysics, has supplied physi-
cians with more durable pacemaker systems
and a variety of techniques for electrical control
of cardiac rate.

JUNE 1970

309

HEART BLOCK / Bowlin

In the normally functioning heart, the sino-
atrial node assumes the role of the primary car-
diac pacemaker. From this site of specialized
muscle tissue located in the sulcus between the
superior vena cava and the right atrium, excita-
tory impulses of depolarization travel through a
rather constant atrial pathway to arrive at the
atrioventricular node located in the inferior atrial
septum. With its slower rhythmicity, the A-V
node further alters and delays excitation before
the wave of depolarization travels via ventricular
pathways through the bundle of His and through
left and right bundles to terminate in the neuro-
muscular Purkinje network. Here it initiates myo-
cardial contraction in the apex which progresses
as a wave-like motion toward the ventricular out-
flow tracks for optimum ventricular emptying
and cardiac efficiency. By far the most common
site of interruption of the conduction system in
patients suffering from chronic heart block is in
the atrioventricular bundle, whether it be recur-
rent block or long-standing chronic block.

The cause of heart block associated with
septum primum defects or block following sur-
gical closure of high ventricular septal defects is
well understood. However, the causal factors in
most instances of acquired heart block are little

Figure 1. Transthoracic epicardial technique of
implantation was the first method of permanent car-
diac pacing generally accepted. An area near the
apex, free of coronary vessels, is selected for direct
suture of the electrode terminals into the myocar-
dium.

understood. We commonly associate arterioscle-
rotic and hypertensive heart disease with heart
block and atrioventricular dissociation; however,
the common denominators of these diseases such
as cardiac enlargement, angina pectoris, severe
systemic hypertension and myocardial infarction
are not commonly encountered in patients with
acquired permanent heart block. Prolonged me-
chanical stress with tissue injury and fibrosis of
the conduction system is thought by some ob-
servers to be a more likely etiologic factor in pa-
tients suffering from acquired heart block.5 Ure-
mia, electrolyte imbalance, myocarditis, endo-
carditis, or drug toxicity (digitalis or quinidine)
may cause acquired heart block by primary in-
volvement of the conduction system or through
myocardial cellular changes.

CARDIAC ASYSTOLE

Robert Adams6 and William Stokes7 first de-
scribed the symptoms of vertigo, convulsions, and
syncope due to profound bradycardia or cardiac
asystole. In patients with permanent block, syn-
copal attacks commonly occur during periods of
increased activity or with further arrhythmias,
but may occur when the patient is at complete
rest. However, we often associate Stokes-Adams
attacks as described with heart block as occurring

Figure 2. This patient's initially implanted epi-
cardial system failed and electrode breakage was
detected on chest x-ray. A permanent endocardial
system was implanted. An improved technique of
electrode application to the epicardium is now being
used which should lessen the chance of electrode
breakage.

310

JOURNAL MSM A

with the sudden development of block and ven-
tricular escape. In patients having heart block
there is approximately an equal division of cases
exhibiting Stokes-Adams attacks or other symp-
toms and signs of inadequate tissue perfusion
and congestive heart failure. Patients with chronic
heart block have systemic hypertension because
of an increase in stroke volume output at the
slow heart rate. Inadequate tissue perfusion can
be documented by an increase in the arterio-
venous oxygen difference and is seen clinically
as cerebral, hepatic, and renal insufficiency. Thus,
it is evident that the physician must suspect heart
block in a variety of presenting symptoms.

Acquired heart block which goes untreated is
a constant threat to the life of the patient. The
effects of heart block are completely unpredict-
able. Patients may go several years with a chron-
ically slow heart rate without any significant
problem, and yet to these patients there is a con-
stant threat of syncopal attacks or fatal arrhyth-
mias. The average duration of life after detec-
tion of heart block is only slightly over two
years.8 In patients having experienced Stokes-
Adams attacks, the mortality increases to 50 per
cent within the first year.9

ISUPREL THERAPY

A long list of sympathomimetic drugs and oth-
er agents have been used in an attempt to in-
crease the idioventricular rate of heart block.
Prior to the development of pacemaker systems,
isoproterenol (Isuprel) was the main mode of
therapy for the entire gamut of heart block pa-
tients. Intravenous Isuprel (two mg. per 1,000 cc.
of physiologic solution) infusion, maintaining a
ventricular rate of 45-50 beats per minute, is now
occasionally needed in the treatment of the acute
Stokes-Adams attack until the patient can be
transported to a center where pacemaker systems
are available. Drug therapy may be lifesaving in
the treatment of the acute syncopal attack but
should not be recommended in the long-term
treatment of the patient with chronic heart block.
Dack10 and Friedberg,11 employing long-term
drug treatment for heart block, experienced mor-
tality rates close to that observed in patients re-
ceiving no treatment.

The four commercially available pacemaker
systems in wide use are the Cordis, Electrodyne,
General Electric, and Medtronic. It is estimated
that approximately 10,000 pacemaker units are
presently in use. The energy source, generally
termed the pulse generator, is supplied by mer-
cury batteries which have a theoretical shelf life of
five years. Experience indicates that replacement

Figure 3. The Medtronic asynchronous permanent
pulse generator and permanent endocardial bipolar
electrode catheter.

of the pulse generator is needed after two and a
half to three years.

Basically there are three types of pacemaker
pulse generators. The asynchronous unit, which
emits electrical impulses at a fixed rate indepen-
dent of the intrinsic cardiac electrical potentials,
is the oldest type unit in use and has proven sat-
isfactory in most cases, especially in the older
and less active patient. The second type of pulse
generator is the synchronous unit, which is de-
signed to correlate the ventricular contraction
with the atrial contraction and thus simulate nor-
mal sinus rhythm. This type of pacemaker unit
requires an additional atrial electrode and is a
more complicated system than the asynchronous
generator. It is reserved for patients with great-
er physical activity or for patients who are in
critical need of maximum cardiac output. The
third type of pulse generator is the demand unit
which is programmed from the R-wave and is
designed so that its own stimulation is suppressed
when the patient’s heart rate is faster than the
pre-set rate of the pulse generator.

THE DEMAND UNIT

This system presently is having an increase in
popularity. It eliminates the potential hazard
(ventricular fibrillation) of the pacemaker firing
during the vulnerable period of ventricular re-
polarization. It also avoids repetition and com-
petition between the pulse generator and idio-
ventricular contractions. Nathan et al12 observed
that after implantation of permanent pacemakers

JUNE 1970

311

HEART BLOCK /Bowlin

for A-V block approximately one-fourth of the
patients reverted to sinus rhythm or second de-
gree block. These patients have competitive foci
of stimulation when paced with an asynchronous
system and may be symptomatic (palpatation and
dyspnea). Thus, demand systems are gaining
preference in patients with pre-operatively high
idioventricular rates and in patients who experi-
ence periodic syncopal attacks with atrioventric-
ular dissociation and otherwise maintain a sinus
rhythm the majority of the time.

There are two operative approaches to the pa-
tient requiring permanent cardiac pacing and the
difference is basically in the type of electrode
system applied. The initial permanent pacemaker
which achieved general acceptance was the epi-
cardial type of electrode application introduced
by Chardack,4 Zoll,13 and Kantrowitz.14 A left
anterior thoracotomy incision is the approach and
the electrode terminals are sutured to the surface
of the left ventricle (Figure 1). In general, this
unit has been quite successful and was the only
method of permanent pacing available until
1964. Breakage of the electrode wire and pre-
mature failure of the pulse generator were the
common causes of failure of the early epicardial
units. Improved electrode terminals with elimina-
tion of constant stress at the point of penetration
of the myocardium has eliminated to a great de-
gree the wire breakage factor.

CLINICAL EXAMPLE

We have had experience with a patient who
three years prior to admission to North Missis-
sippi Medical Center had implantation of a per-
manent epicardial unit (Figure 2) and had two
pulse generator replacements, followed by anoth-
er syncopal attack. On chest x-ray breakage of an
electrode terminal was noted. The patient would
experience syncopal attacks when in the upright
position, but would pace satisfactorily in the re-
cumbent position when the ends of the broken
electrode were in contact. The x-ray shows that
a permanent type of transvenous pacing system
was used to replace his former unit. The pri-
mary disadvantage of the epicardial method of
application is the need for thoracotomy with gen-
eral anesthesia. This method of implantation is
presently being used only in younger, more ac-
tive patients who may also be candidates for the
more complicated synchronous type pacemaker.

The second method of electrode application,
employing a permanent transvenous endocardial
catheter (Figure 3), was introduced in 1965 by

Chardack15 and is a simplified method when
compared with the epicardial type unit in that
this application does not require a general anes-
thetic or a thoracotomy (Figure 4), but is im-
planted by means of transvenous passage of a
permanent electrode catheter through a cervical
vein into the right ventricle where the electrode
terminal is wedged in the trabecular musculature
of the cardiac apex under fluoroscopic control
(Figure 5). The complete procedure is performed
under local anesthesia. The generator is placed in
a subcutaneous or subpectoral pocket and the
electrode catheter is connected by way of a tun-
nel between the cervical and pectoral wounds
(Figure 3). Anticoagulation is unnecessary.

ENDOCARDIAL SYSTEM

Danielson,16 et al, found the endocardial pac-
ing system of particular value in patients exhib-
iting failure of previously implanted epicardial
units. Not only could the procedure be done un-
der local anesthesia but the previously implanted
epicardial electrodes could be left in place un-
disturbed, with only the old pulse generator re-
moved. They reported eight patients underwent
replacement by endocardial electrode system;
seven of eight failures were due to wire break-
age.

Long-term electrical pacing of the heart has
unequivocally become the treatment of choice in
symptomatic heart block, whether the symptoms
be syncopal attacks or symptoms of cardiac de-
compensation. One Stokes-Adams attack is indi-
cation enough for implantation of a permanent
pacing system. Decreased exercise tolerance, re-
nal or cerebral impairment and perhaps angina
are additional symptomatic indications for per-
manent pacing. Not infrequently both the patient
and physician will notice a great improvement
in general strength and mental alertness of a post-
operative patient who pre-operatively was con-
sidered asymptomatic except for Stokes-Adams
attacks. We have experienced this change fre-
quently.

TRANSVENOUS SYSTEM

With development of the transvenous endo-
cardiac electrode system, age is no longer a con-
traindication to pacemaker implantation. With
improvements in materials and methods of ap-
plication, asymptomatic patients with idioventric-
ular rates less than 40 or whose EKG’s show pat-
terns of ventricular irritability17 are now recom-
mended for permanent pacing. The non-opera-
tive management of these patients is considered
more hazardous and radical than management
by permanent pacing systems. Congenital heart

312

JOURNAL MSMA

Figure 4. Permanent endocardial pacemaker show-
ing catheter electrode terminals in the apex of the
right ventricle. The pulse generator is located in the
subcutaneous pocket of the right pectoral area.

blocks producing symptoms or demonstrating
widened QRS complexes on EKG’s should have
implantation of a permanent pacemaking system.
Sinus bradycardia or sinus arrest, if symptomatic,
should be treated by implantation of permanent
pacemakers.

Post-operative tachyarrhythmias and second or
third degree block with acute myocardial infarc-
tions may require use of a temporary pacing
catheter. Heart block, when present, usually de-
velops within 36 hours after occurrence of a
myocardial infarction. The incidence of block is
highest with inferior infarctions but associated
with the highest mortality in anterior infarctions.
Of patients recovering from infarction only 5 to
8 per cent will persist to have permanent block.
Use of a temporary pacing catheter improves the
cardiac output by increasing the cardiac rate. Ar-
tificial pacing removes the threat of Stokes-Adams
attacks, which carry a higher mortality in patients
with myocardial infarctions. Probably most sig-
nificant, use of the temporary pacing catheter
eliminates the need for Isuprel and other drugs
producing cardiac irritability but allows the use
of digitalis and suppressant drugs without com-

Figure 5. Photograph of our first patient: pace-
maker implanted February, 1967. This photograph
was made recently, following replacement of the
pulse generator for impending battery failure. Note
the cervical and pectoral incision scars.

pounding A-V conduction problems. In our ex-
perience with the use of a temporary pacing
catheter in heart block, secondary to myocardial
infarctions, uremia and electrolyte imbalance,
four of six patients survived.

To insure complete and optimal care for the
patient with heart block we have found it bene-
ficial to divide management of the patient into
four phases, beginning with admission to the hos-
pital and extending into the post-hospitalization
period.

(1) The period of intensive observation: On
admission to the hospital all patients having com-
plete heart block or suspected of having had
complete heart block or Stokes-Adams attacks
are placed in the Intensive Care Unit where they
are continuously monitored by electrocardio-
graphic equipment with a defibrillator and ex-
ternal pacemaker at the bedside at all times.
Routine laboratory studies including electrocardi-
ogram, chest x-ray, and serum chemistry profiles
are performed. Studies obtained during the initial
few hours of hospitalization exclude acute myo-
cardial infarction, uremia, and electrolyte imbal-

313

JUNE 1970

HEART BLOCK / Bowlin

ance as causal factors in the heart block. A so-
lution of isoproterenol (Isuprel — 2 mg. per 1,000
cc. of physiologic solution) is placed in the im-
mediate area of the patient for use in case of
Stokes-Adams attack. We do not recommend the
routine use of a constant infusion of Isuprel in
the patient with chronic heart block during this
initial period, especially when there is evidence
of ventricular irritability.

TEMPORARY CATHETER

(2) Passage of a temporary transvenous pac-
ing catheter: We advise passage of a temporary
pacing catheter in patients with chronic heart
block and particularly in those having experi-
enced Stokes-Adams attacks as soon after admis-
sion as feasible, preferably the day of admission.
The introduction of this pacing system removes
the always constant threat of Stokes-Adams at-
tacks. This early phase of hospitalization when
various medications are administered is a pre-
carious period in patients with chronic heart
block. Temporary pacing not only allows for
early improvement and stabilization of the pa-
tient’s condition but also eliminates the need for
Isuprel infusion. Cardiac output is improved and
congestive heart failure clears. The temporary
pacing catheter is passed through the basilic
vein into the apex of the right ventricle and with
the use of an external pacer both amperage and
rate alterations are available. In patients in whom
operative procedures for some other condition is
anticipated, the temporary pacing is maintained
throughout the surgery to be followed by im-
plantation of a permanent pacing system. Use of
the temporary pacing system removes the neces-
sity for urgent implantation of a permanent sys-
tem and yet improves and stabilizes the con-
dition of the patient.

(3) Implantation of the permanent pacing
system: We now feel that with the possible ex-
ception of the young, active patient, in whom a
synchronous unit is perhaps indicated, candidates
for permanent pacing should have implantation
of endocardial transvenous pacing systems. This
system has a smaller morbidity and mortality
rate immediately post-operatively and long-term
results are just as good as those seen with epi-
cardial units. Implantation of the permanent en-
docardiac system is scheduled several days in ad-
vance. During the period of preparation the heart
is paced by the temporary catheter. It is essen-
tial that the surgeon be thoroughly familiar with
all monitoring equipment and the entire gamut

of pacing equipment. During the operative pro-
cedure patients are monitored continuously by
electrocardiogram with external defibrillators and
pacing equipment available. The procedure is
performed under local anesthesia with the anes-
thetist monitoring vital signs. The external jugular
vein on the right side is exposed and if of ade-
quate diameter, is used for passage of the elec-
trode catheter into the right ventricle using fluo-
roscopic guidance. The internal jugular vein is
immediately available through the same incision
when the external vein is of inadequate size.
Threshold potentials are determined for both
electrodes, and optimum position of the electrode
terminal is obtained. After complete connection
of the permanent catheter to the permanent pulse
generator the external pacing system is shut off
and the procedure terminated. The patient is ob-
served in the Intensive Care Unit for an additional
24 hours following implantation and during this
period is monitored continuously by electrocar-
diogram. We have adopted the policy of leav-
ing the external temporary pacing catheter in
place in the right ventricle for the first 24 to 48
hours following implantation of the permanent
system to insure availability of an effective pac-
ing system in the event the permanent catheter
dislocates from the right ventricle. We have never
regretted this policy and have slept better know-
ing that the auxiliary pacing system is immedi-
ately available at the flip of a switch.

FOLLOW-UP

(4) Periodic long-term follow-up: It is es-
sential to have three to six-month interval follow-
up examinations, including chest x-ray and elec-
trocardiogram. A decrease in contrast of the bat-
teries on x-ray, a change in the rate of the pac-
ing artifact (asynchronous unit) of more than
four beats per minute, incomplete capture of the
pacemaker or a decrease in amplitude of the ar-
tifact as seen on electrocardiogram are all signs
of impending pulse generator failure.

During the period from Feb. 1967 to Sept.
1969, 22 patients have had implantation of per-
manent cardiac pacemakers at the North Mis-
sissippi Medical Center. Four patients have re-
quired replacement of the pulse generator, three
for impending late battery failure and one for
symptomatic competitive rhythm which developed
one year after implantation of an asynchronous
pulse generator. Twenty patients have had im-
plantation of permanent transvenous endocardiac
units, and two patients received epicardial elec-
trode systems. All patients have received Med-
tronic pacing units. Demand pulse generators

3 14

JOURNAL MSM A

were used in 10 patients and 12 patients re-
ceived asynchronous fixed rate units.

The ages of the patients ranged from 62 to
88 years, with a median age of 75. The electro-
cardiogram showed chronic complete heart block
in 18 patients and intermittent block or arrhyth-
mia in four patients. Fourteen patients had ex-
perienced syncopal attacks and eight patients had
symptoms only of congestive heart failure. No
patients had experienced angina. None of the pa-
tients were known to have developed block fol-
lowing myocardial infarctions. There was a wide
variation in the duration of symptoms. Improve-
ment in general strength and alertness of the pa-
tient was uniformly observed following implanta-
tion of pacemakers.

DISLOCATION

There have been two cases of early dislocation
of the endocardial catheter tip from the right
ventricle. The instance of this complication is re-
ported at 10-15 per cent. We have adapted sev-
eral advantageous technical maneuvers which
have diminished the likelihood of this complica-
tion and have not experienced its appearance in
any of the last 14 implantations. Dislocation of
the catheter tip usually occurs within the first 24
hours following implantation, and thus we strong-
ly feel the need for leaving the temporary pacing
catheter in place for 24 to 48 hours following
implantation of the permanent system. Disloca-
tion of the permanent catheter tip is more likely
if incomplete capture by the pacemaker is pres-
ent or if multifocal idioventricular contractions
are present. We have found the intravenous use
of Xylocaine very helpful in suppressing these
multifocal contractions in the early post-operative
period.

We have experienced no cases of early or late
myocardial perforations by the catheter tip.
Most reported cases of perforation occurred in
early series of cases when the electrode stylets
were being left in place, and now that they are
being removed this complication should be less
frequent. We have had no cases of electrode
breakage.

One patient experienced left diaphragmatic
pacing for a brief period which cleared spon-
taneously. Close proximity of the pacing electrode
to the left phrenic nerve causes this diaphragmat-
ic twitching which can be bothersome though not
detrimental to the patient. Several years ago we
experienced this complication persisting until it
was completely abated by crushing of the phrenic
nerve in the neck.16

Infections occurring about a pacing catheter
usually result in failure to pace and necessitates

staged implantation of a completely new unit at
a different site.18 We credit the absence of any
infections in this series to meticulous skin prep-
aration and surgical technique with absolute he-
mostasis and the use of Hemovac suction for five
post-operative days. Heavy prophylactic antibi-
otic coverage against gram negative and gram
positive organisms was administered.

GENERATOR REPLACEMENT

Late battery weakness with incomplete cap-
ture by the pacemaker prompted replacement of
the pulse generator in two patients, and an in-
crease in rate of 12 artifact stimuli per minute in
association with occasional sub-threshold stimula-
tion 18 months after implantation with the indi-
cation for pulse generator replacement in one
other patient.

There have been two early deaths, one sec-
ondary to pacemaker failure caused by post-
pericardiotomy syndrome following implantation
of an epicardial pacing unit. The second early
death was caused by a pulmonary embolus in a
patient who had a fractured hip pinned after im-
plantation of a transvenous pacing system. There
have been three late deaths. One patient devel-
oped a repetitive rhythm of exactly two times
the pacemaker rate (asynchronous unit) and
went into refractory ventricular fibrillation before
the pacemaker catheter could be severed. Two
patients died five and six months after implanta-
tion from progressive cardiac failure though they
were being paced satisfactorily at the time of
death.

SUMMARY

Within the last decade the development of re-
liable permanent pacing systems has dramatical-
ly altered the mortality and morbidity of heart
block and Stokes-Adams attacks, so that patients
with chronic slow heart beat can look forward to
a more productive and longer life. There is no
place for long-term drug treatment in the man-
agement of complete heart block. The “asymp-
tomatic” as well as the symptomatic patient may
require pacing. Development of a more durable
energy source is now the primary objective in
the improvement of pacing systems. The trans-
venous endocardial system is superior to the
transthoracic epicardial system and should be
the system applied to elderly patients suffering
from Stokes-Adams attacks and chronic heart
block. We feel that the demand pacing system
is indicated in all patients requiring permanent
pacing because of the elimination of repetitive
and competitive rhythm as well as for conserva-
tion of battery strength. ***

812 Garfield St. (38801)

3 15

in
c q
) ; '5

JUNE 1970

REFERENCES

1. Hyman, A. S.: Resuscitation of a Stopped Heart by
Intracardial Therapy, A.M.A. Arch. Int. Med. 50:
283, 1932.

2. Zoll, P. M.: Resuscitation of the Heart in Ventricu-
lar Standstill by External Electric Stimulation, New
England J. Med. 247:68, 1952.

3. Weirich, W. L.; Poneth. M.; Gott, V. L.; and Lille-
hei, C. W.: Control of Complete Heart Block by
Use of an Artificial Pacemaker and Myocardial
Electrode, Circulation Research 6:410, 1958.

4. Chardack, W. M.; Gage, A. A.; and Greatbatch, W. :
Correction of Complete Heart Block by Self-Con-
tained and Subcutaneously Implanted Pacemaker,
J. Thoracic Surg. 42:814, 1961.

5. Liev, M.: The Normal Anatomy of the Conduction
System in Man and Its Pathology in Atrioventricular
Block, Ann. N. Y. Acad. Sc. 3:817, 1964.

6. Adams, R.: Cases of Diseases of the Heart Accom-
panied With Pathological Observations, Dublin Hos-
pital Reports 4:353-453, 1827.

7. Stokes, W. : Observations on Some Cases of Perma-
nent Slow Pulses, Dublin Quart. J. Med. Sc. 2:73-85,
1846.

8. Penton, G. B.; Miller, H.; and Levine, S. A.: Some
Clinical Features of Complete Heart Block, Circula-
tion 13:801-825 (June) 1956.

9. Johansson, B. W.: Adams-Stokes Syndrome: A Re-
view and Follow-Up Study of Forty-Two Cases, Am.
J. Cardiology 8:76-93 (July) 1961.

10. Dack, S. : Pacemaker Therapy in Heart Block and
Stokes-Adams Syndrome, J. A.M.A. 191:846-848
(March 8) 1965.

11. Friedberg, C. K.; Donoso, E.; and Stein, W. G.:
Non-Surgical Acquired Heart Block, Ann. N. Y.
Acad. Sc. 3:835-847, 1964.

12. Nathan, D. A.; Center, S.; Wu, C. Y.; and Kel-
ler, W.: An Implantable Synchronous Pacemaker
for the Long-Term Correction of Complete Heart
Block, Am. J. Cardiol. 11:362, 1963.

13. Zoll, P. M.; Frank, H. A.; Zarsky, L. R. N.; Linen-
thal, A. J.; and Belgard, A. H.: Long-Term Electric
Stimulation of the Heart for Stokes-Adams Disease,
Ann. Surg. 154:330-346.

14. Kantrowitz, A.; Cohen, R.; Raillard, H.; and
Schmidt, J.: Experimental and Clinical Experience
With a New Implantable Cardiac Pacemaker.

15. Chardack, W., et al: The Long-Term Treatment of
Heart Block, Prog. Cardiovas. Dis. 9:105 (Sept.)
1966.

16. Danielson, Gordon K.; Bryant, Lerten R.; Bowlin,
John W.; and Mallette, William G. : Pacemaker
Therapy in Complete Heart Block: Current Con-
cepts of Management, Ky. M. J. (Nov.) 1966.

17. Hollingsworth, J. Hayden; Muller, William H.;
Beckwith, Julian R.; and McGuire, Lockhart B.:
Patient Selection for Permanent Cardiac Pacing,
Ann. Int. Med. 70:263 (Feb.) 1969.

18. Firor, W. B.; Lopez, J. F.; Nanson, E. M.; and
Mori, M.: Clinical Management of the Infected
Pacemaker, Ann. Thoracic Surg. 6:431-436, 1968.

FREUDIAN SLIP

A young chaplain, new with the prison system, was sent to
console an inmate soon to be electrocuted. As the prisoner was
being led to the electric chair, the flustered chaplain, not wanting
to say, “Goodbye,” which sounded terribly final; or “See you
later,” that really wasn't what he wanted; finally spoke to the
condemned man, “More power to you,” he said.

—From the Mississippi Educational Advance

316

JOURNAL MSMA

Artificial Kidneys
In Acute Renal Failure

JOHN D. BOWER, M.D.
Jackson, Mississippi

Acute renal failure may be defined as the
sudden cessation of renal excretory and hemo-
static function. It is divided into three classifica-
tions for diagnostic and therapeutic purposes.
This classification consists of post-renal failure,
pre-renal failure, and parenchymal renal failure.
All of these have been discussed, and the mech-
anisms for diagnosing each of these parameters
of renal function have appeared in a previous
publication.1 This paper then will deal with the
management of parenchymal renal failure some-
times referred to as lower nephrosis, or prefer-
ably called acute tubular necrosis. Specifically,
the use of the artificial kidney in the manage-
ment of acute tubular necrosis will be discussed,
and the results of experience in 35 consecutive
cases of acute tubular necrosis requiring hemo-
dialysis will be presented in detail.

Between Oct. 1, 1966, and Feb. 15, 1970, 160
hemodialyses were performed in 35 patients for
acute renal failure. All of these had acute tubular
necrosis except one who was dialyzed for gross
fluid overload following ureteral ligation of her
solitary ureter. Of these 35 patients, 20 are sur-
viving and have had adequate return of renal
function to maintain life without dialysis.

The precipitating factors, their frequency, and
the survival rates in each group are shown in
Table 1. It is seen that 11 of these 35 patients
developed tubular necrosis in the post-operative
period. This condition was usually associated
with extensive surgical procedures accompanied
by excessive bleeding or severe sepsis develop-

From the Department of Medicine, University of Missis-
sippi School of Medicine.

ing two to three days postoperatively. These pa-
tients were predominantly elderly and had a very
poor survival rate. The next most common cause

During the last three years, 160 hemo-
dialyses have been performed in 35 pa-
tients for acute renal failure at the Univer-
sity Medical Center. Twenty are still sur-
viving. The author discusses the use of the
artificial kidney in the management of acute
tubular necrosis and presents the results of
experience in these 35 cases.

of acute tubular necrosis was automobile acci-
dents. Tubular necrosis in this group was due to
excessive blood loss at the time of the automo-
bile accident, or subsequent dehydration due to
inadequate fluid replacement after the patient
had been hospitalized. Nephrotoxic agents were
the next most common cause.

One case was due to an overdose of Strep-
tomycin, another to an overdose of Kanamycin.
and one to carbon tetrachloride ingestion. One
case resulted from prolonged inhalation of gaso-
line fumes with resultant severe pneumonia and
acute tubular necrosis. The medical diseases that
precipitated this condition were septicemia fol-
lowing cholecystitis, hypercalcemic nephrotoxici-
ty of primary hyper-parathyroidism. massive gas-
trointestinal hemorrhage, and a case of non-ke-
totic hyperosmolar coma in a patient with dia-
betes mellitus. This category of medical diseases
likewise carried a significant mortality with two

JUNE 1970

317

ARTIFICIAL KIDNEYS / Bower

of the patients dying of sepsis, and one of ex-
sanguination.

Two cases of acute tubular necrosis resulted
from gunshot wounds of the abdomen with mul-
tiple through and through perforations of the
bowel, producing soiling in the peritoneal cavity
and septicemia. Neither of these patients sur-
vived because of the extensive intra-abdominal
and systemic septicemia. Two cases of acute tu-
bular necrosis occurred in the post-partum peri-
od, both resulting from abruptio placenta. Both
of these patients had adequate return of renal
function after prolonged dialysis. One of these re-
quired three months to regain function. Criminal
abortion was responsible for acute tubular ne-
crosis in two cases, in one of which treatment
was ultimately abandoned due to irreversible
brain damage from multiple brain abscesses.

Two patients in this series received incom-

TABLE 1

PRECIPITATING FACTORS
IN ACUTE TUBULAR NECROSIS

Survival

Per Cent

Post-operative

1 1

4

36

Auto accidents

5

4

80

Toxic agents

4

4

100

Medical disease

4

1

25

Gunshot

2

0

0

Postpartum

2

2

100

Abortion

. . . . . 2

1

50

Transfusion

2

2

100

Burn

1

0

0

Heat stroke

1

1

100

Drug reaction

1

1

100

35

20

57.1

TABLE 2

MEDIATING FACTORS
IN ACUTE TUBULAR NECROSIS

Survival Per Cent

Sepsis 14 2 14

Hemorrhage 8 7 87

Dehydration 4 4 100

Nephrotoxin 3 3 100

Transfusion 2 2 100

Drugs 1 1 100

Renal emboli 1 1 100

Heat stroke 1 1 100

Obstruction 1 1 100

patable blood. Both of these had an adequate
return of renal function. The other causes of acute
tubular necrosis consisted of one burn with se-
vere sepsis, a heat stroke with massive muscle
heat coagulation, and an adverse drug reaction
producing profound hypotension and shock.

TABLE 3

AVERAGE NUMBER OF DIALYSES

Average/

No.

Total

Patient

Living

20

1 17

5.85

Dead

15

43

2.87

The mechanism by which acute tubular ne-
crosis evolves is not known. No predictable ani-
mal model has ever been developed to permit
precise quantitation of the variables involved in
precipitating this condition. For this reason, many
mediating factors have been speculated upon, but
the most common factor seems to be renal hy-
poxia due to many mediating factors. The me-
diating factors in this series of acute tubular ne-
crosis are shown in Table 2. Severe infection or
sepsis is the commonest factor responsible for
acute tubular necrosis in this series. Fourteen of
the 35 patients who were dialyzed for acute tu-
bular necrosis had the condition develop second-
ary to overwhelming sepsis. There was only a
14 per cent survival rate in this group. Again the
great majority of these septic conditions devel-
oped in the postoperative period.

TUBULAR NECROSIS

Excessive blood loss was responsible for 8 of
the cases of acute tubular necrosis with only one
mortality. The remainder of the mediating fac-
tors did not cause any death in this series of
patients with acute tubular necrosis. Dehydration
was responsible for four of these conditions, and
all were salvaged. The same is true of nephrotox-
ic agents which usually have an adequate return
of renal function after the transient period of
acute tubular necrosis. Both of the transfusion
reactions did quite well. The patient recovered
from acute tubular necrosis following shock sec-
ondary to drug abuse. One patient had a renal
embolus which was removed from the renal ar-
tery with resultant adequate return of renal func-
tion. Both patients with heat stroke and obstruc-
tion of the solitary ureter had an adequate re-
turn of renal function.

The average number of dialyses per patient is
shown in Table 3. Of the 20 patients that are

318

JOURNAL MSM A

living, there were 117 hemodialyses performed
with an average of 5.85 dialyses per patient. In
the 15 patients who died, the average dialyses
per patient was 2.87.

Of the 15 patients who died, the cause of
death is shown in Table 4. It is seen that the
overwhelming cause of death in patients suffer-
ing from acute tubular necrosis is sepsis. Thirteen
of the 15 patients died of septicemia. Death was
predominately due to gram negative organisms.
One patient exsanguinated from a recurrent
bleeding duodenal ulcer, and one patient had a
cerebral vascular accident following dialysis. It is
noteworthy that none of these patients died of
uremia.

The relationship of age to survival and the
distribution of acute tubular necrosis according
to age is shown in Table 5. From this figure it
can be seen that patients over 60 had very poor
survival rates. The reason for this is due pri-
marily to the fact that most of these patients were
quite debilitated. Many had advanced arterio-
sclerosis and congestive failure in the pre-op-
erative period. The great majority of the patients
in this group came from the postoperative cate-
gory and were also severely infected.

CONSERVATIVE MANAGEMENT

Acute tubular necrosis can be managed con-
servatively without the use of hemodialysis in the
majority of cases. It is estimated that 80 to 90
per cent of cases of acute tubular necrosis can
be handled by medical means. The series pre-
sented, however, is not representative of cases
usually seen in the community hospital. By and
large, the cases referred to the Medical Center
have been screened by local physicians and for
this reason the incidence of dialytic therapy is
approximately 30 per cent.

Even when dialysis has been decided upon,
the patient, in most instances, could be man-
aged with peritoneal dialysis. The only advan-
tage to hemodialysis over peritoneal dialysis is
that it is much more rapid, and requires less time.
Other factors being equal, however, unless the
patient is extremely catabolic or has multiple
perforations in the peritoneal cavity, then peri-
toneal dialysis will suffice. Many patients at the
Medical Center are handled with peritoneal di-
alysis, but in the series presented the patients
were treated with hemodialysis primarily be-
cause of the availability of this method of treat-
ment, and the shorter period of time required
to carry out this procedure. Many of the cases in
this series were extremely catabolic and could
not be handled by peritoneal dialysis.

The indications for dialytic therapy in the man-
agement of acute tubular necrosis can be made
on either clinical or laboratory criteria. We use
a composite of these two. We continue conserva-
tive therapy unless the patient’s condition shows
definite evidence of deterioration as manifested

TABLE 4

CAUSES OF DEATH
IN ACUTE TUBULAR NECROSIS

Sepsis 13

Hemorrhage 1

CVA . . . 1

Uremia 0

by persistent nausea and vomiting, lethargy, dis-
orientation, coma, convulsions, or overhydration.
We also take into consideration the severity of
the catabolic condition, the amount of necrotic
or infected tissue that the patient has, and the
time in the natural evolution of the disease in
which we see the patient.

Chemical indications for dialysis include a ris-
ing potassium that cannot be controlled by a
conventional method, a rapid rise of blood urea
nitrogen above 150 mg. per cent, or in excess of
40 mg. per cent per day, and a serum creatinine
in excess of 12 mg. per cent. If the serum creat-
inine is rising at the rate of 2 mg. per cent per
day, this is compatible with severe impairment of
kidney function unless there is extreme break-
down of muscle tissue in the patient. The de-
gree of acidosis is also considered if the COo com-
bining power is below 14 mEq/L.

EARLIER DIALYSIS

More recently, we have adopted a policy of
earlier rather than later dialysis, and we have
also adopted the policy that once we have com-
mitted ourselves to this method of treatment di-
alysis should be used not only to remove the pa-
tient from the uremic state, but to bring his
blood chemistries to within normal limits and
maintain them at near normal limits. The avail-
ability of hemodialysis on a large scale has per-
mitted us to achieve this objective in these pa-
tients.

All of our hemodialyses were performed using
either the Kolff twin coil kidney, or the Kiil flat
plate hemodialyzer. The patients routinely have
an arterio-venous shunt installed between the ra-
dial artery and a forearm vein so that subsequent
hemodialyses can be performed by the nursing
staff. No blood prime is required to operate the
Kiil dialyzer. This dialyzer is usually preferred
for this reason.

IUNE 1970

319

ARTIFICIAL KIDNEYS / Bower

Dialysis is performed for approximately 12
hours three to four times per week during the
profound oliguric phase. In order to prevent the
hazards of bleeding during the hemodialysis pe-
riod the patient is kept on regional hepariniza-
tion whereby protamine is infused into the blood
just prior to returning to the patient to neutralize
the heparin that is infused into the blood just as
it is leaving the patient. The maintenance of nor-
mal clotting time as determined by the Lee-
White method is possible with this technique.

When the patient is not on hemodialysis, the
electrolytes, BUN, creatinine and CBC are de-
termined at daily intervals. The rate of rise in
creatinine and the onset of the diuretic phase
are the primary determinations in discontinuing
this method of therapy. When the patient is able
to maintain his own serum creatinine and is put-
ting out in excess of 1,000 ml. of urine per 24
hours, then hemodialysis is discontinued. Subse-
quent to this the patient will frequently under-go
a diuretic phase and then have adequate return
of sufficient renal function to maintain life.

In this series of 35 patients, there is a 57.14

TABLE 5

RELATIONSHIP OF AGE TO SURVIVAL

Age(Yrs.) No. Survival PerCent

10-20 3 3 100

20-30 4 4 100

30-40 6 3 50

40-50 4 3 75

50-60 9 6 66

60-70 6 1 16

70+ 3 0 0

per cent survival rate. Twenty of the 35 patients
left the hospital with adequate renal function to
live. Of the 15 patients who succumbed in this

series, infection or septicemia was the precipitat-
ing cause of kidney failure in 12 cases. One ad-
ditional patient was lost to sepsis in whom mas-
sive gastrointestinal bleeding was the cause of
tubular necrosis. One additional patient died of
hemorrhage, and one patient had a cerebral vas-
cular accident shortly after hemodialysis was
completed. The highest mortality occurred in
post-operative patients. It is felt that the com-
bination of malnutrition, severe underlying dis-
ease that prompted the surgery, and the septic
state present in these patients are the factors de-
termining the outcome in this series. The elderly
patient has a much worse prognosis due primarily
to the severity of his underlying disease, and oth-
er predisposing factors of his age.

SUMMARY

One of the major “spin-off” benefits of a
chronic hemodialysis program is the availability
of the artificial kidney for the management of
acute renal failure. In the past 39 months we
have performed 160 hemodialyses in 35 patients
with acute tubular necrosis. Twenty of these pa-
tients have had an adequate return of renal
function to maintain life without hemodialysis.
Fifteen of these patients died. Of the 15 deaths,
13 were attributable to sepsis which in 12 in-
stances was the cause of the acute tubular ne-
crosis. Two additional deaths occurred, neither
of which was related to uremic poisoning. All of
the patients in this series were in need of dialysis
as determined by the criterion previously stated.
It is concluded then that in patients with acute
renal failure, the survival rate is more dependent
upon the etiology of the renal failure than upon
the acute tubular necrosis itself. No patient should
die of acute renal failure.

2500 N. State St. (39216)

REFERENCE

1. Bower, J. D., and Brent, A. E.: Acute Renal Failure,

J. Miss. M. A. VIII: 542-548 (Sept.) 1967.

320

JOURNAL MSMA

Potassium Therapy
And Gastrointestinal Lesions

DAVID N. EMERSON, Ph.D.

Evansville, Indiana

The first group of thiazide diuretics was in-
troduced into clinical use in 1957. Since increased
potassium excretion is one of the effects of thia-
zides, potassium supplementation became a com-
mon procedure in thiazide therapy. The first of
several combinations of a thiazide with potassi-
um chloride in a single tablet was introduced in
1959. Prior to 1963, only 170 cases of pri-
mary nonspecific ulceration of the small intestine
had been reported in the literature.1

The first report that serious gastrointestinal
distress was associated with KCl-thiazide thera-
py appeared in 1961, but received little atten-
tion.2 The problem became of intense interest
during 1964 with reports which linked stenosing
ulcers of the small bowel with potassium-thia-
zide therapy.3- 4 Most of the patients involved
had been treated with a thiazide, often supple-
mented with potassium. During 1964, two phar-
maceutical companies in cooperation with the
Food and Drug Administration analyzed records
in 488 domestic and foreign hospitals. The re-
sults revealed that of 484 patients with the char-
acteristic type of intestinal lesion, 275 (57 per
cent) had a history of administration of either
potassium, a diuretic, or both.5 Subsequent to
these early reports linking small-bowel ulcera-
tion with potassium and/or diuretic therapy, re-
ports of additional cases (Table 1), editorials and
other comments have been published.26-33

The incidence of potassium-induced lesions of

From the Mead Johnson Research Center.

the small bowel has been reported in several
ways. Based on the total numbers of hospital rec-
ords of all patients in 321 hospitals over 21 years,
211 out of 17,805,097 (1.2/100,000 patients)

Prior to widespread clinical use of thia-
zide diuretics in combination with potassium
chloride only 170 cases of primary nonspe-
cific ulceration of the small intestine had
been reported in the literature. By 1964 re-
ports linked stenosing ulcer of the small bow-
el with potassium-thiazide therapy. The au-
thor reviews pertinent literature and con-
cludes that the KCl component of the tab-
lets is the harmful entity. He notes that cur-
rent evidence supports the primary vascular
origin of the lesions.

definitely or likely had lesions of the type as-
sociated with potassium.30 On a different basis,
11 out of 473 patients (2.3 per cent) who were
on enteric-coated KCl administration were re-
ported to have typical potassium-induced le-
sions.3 A third way of describing incidence is
from the survey of Lawrason, et al.5 Of a total
of 484 patients with typical lesions, 275 (57
per cent) had received diuretics or KCl. How-
ever, it has been pointed out that inaccuracies of
record keeping would be responsible for a lower
percentage of cause-effect relationships10 and Bo-
ley et al42 note in a careful investigation of 125

JUNE 1970

321

POTASSIUM THERAPY / Emerson

patients not included in the mass survey of Law-
rason, et al, that potassium ingestion was estab-
lished definitely in 93 per cent and probably in
another 3 per cent. Their conclusion was that the
increase of circumferential small-bowel lesions
must be attributed to enteric-coated potassium.

Information linking potassium administration
to small-bowel lesions resulted in FDA regula-
tions on warnings for potassium salt prepara-
tions intended for oral ingestion by man. The
warnings are not required on preparations dis-
solved in an adequate quantity of liquid so that
the concentration of potassium is below a 20
mg/ml limit, if it is a prescription item, and if its
labeling bears adequate information for use.35
The FDA has recently proposed that all fixed
combinations of diuretic and enteric-coated po-
tassium be removed from the market. This ac-
tion has been taken as a result of recommenda-
tions of NAS/NRC review panels that such
combination drugs present more potential haz-
ards than other types of potassium supplements
which are available.36

TABLE 1

SMALL-BOWEL LESIONS REPORTED
IN POTASSIUM THERAPY

Therapy

Total Number
of Cases a

References

Enteric-Coated KC1 plus

Thiazide or KC1 alone .

4 1 1 b

3-24

Non-Enteric Coated K-Salts

plus Thiazide

3C

23-25

a The Food and Drug Administration has recently
reviewed records of 122 cases.52 Small-bowel lesions were
found in 112 cases on thiazide-potassium enteric-coated
tablets; 6 cases on diuretic plus enteric-coated potassium
given separately; and 4 cases on oral diuretic without
potassium.

b In 275 cases reported by Lawrason, et al,5 type of
diuretic was not specified; therapy was potassium, a
diuretic, or both.

c Includes 2 cases associated with potassium gluconate
and 1 case associated with a potassium acetate-bicar-
bonate-citrate mixture.

The exhaustive retrospective studies of clinical
records5 strongly indicated that the nonspecific
intestinal ulcers seen in man were probably
caused by enteric-coated tablets containing KC1
plus a thiazide diuretic. Initial questions were
raised that the ulcerations could have been
caused by any or all of the ingredients of these

tablets. However, the incidence of the lesions l
was so small that statistical methods and large
numbers of case reports had to be used to estab-
lish a cause-effect relationship. Only after animal
experimentation was it shown that potassium
chloride alone, and not the thiazide diuretic or
the enteric coating of the tablet, was responsible
for the injury to the intestinal tract.

DOG EXPERIMENTS

An experimental model in dogs simulated an
extreme situation in which a tablet would be
entirely dissolved over a short length of intes-
tine.34 Tablets included enteric-coated placebos,
enteric-coated KC1, various enteric-coated thia-
zide-potassium preparations, and thiazides alone.
The tablets were fixed within the ileum or distal
jejunum so that dissolution and absorption of
their contents occurred within a short segment of
the intestine. No pathologic changes occurred
from enteric-coated placebos or thiazides alone.
With the KC1 or the thiazide-KCl combinations,
ulcerations occurred in varying degrees in both
jejunum and ileum. The prerequisite for ulcera-
tion apparently was absorption of KC1 in high
concentration over a short length of bowel. There
was a suggestion that higher doses of KC1 caused
more severe ulceration.

Enteric-coated tablets which contained placebo,
thiazide, KC1, and thiazide plus KC1 were ad-
ministered to rhesus monkeys.37-39 Only KC1
and KC1 plus thiazide produced ulcerations; thia-
dize or enteric coats alone did not. The lesions
were not consistently produced in the small intes-
tine; sometimes the stomach, the cecum, or the co-
lon were affected. It appeared that ulcerations usu-
ally occurred where the greatest amount of potas-
sium chloride was released from the tablet. It
became apparent that tablets with short disinte-
gration times produced lesions in the stomach or
upper intestine, while tablets with long disin-
tegration times produced ulcerations in the low-
er intestinal tract. Liquid preparations containing
approximately 13.5 mEq potassium per 5 ml.
(equivalent to 1,000 mg. of KC1) were chiefly
irritating to the stomach. Lesions were produced
within five days by 1,000 or 250 mg. KC1 in
enteric-coated tablets twice daily. However, the
250 mg. dosage caused milder lesions which
could not be predictably reproduced, while tab-
lets of 100 mg. were without effect. Tablet di-
mensions were not a factor in production of le-
sions.

When the upper ileum of dogs was partially
obstructed with Teflon bands, acute mucosal ul-
ceration resulted from administration of KC1

322

JOURNAL MSMA

alone or in combination with thiazides. Thiazides
alone did not produce ulceration.40

Lesions have appeared up to two years after
discontinuing potassium administration;19 as few
as two tablets have been implicated;7 age of pa-
tients has been as low as 2 years;11 and lesions
may be reversible in some cases.6 Recurrent, usu-
ally postprandial, crampy abdominal pain is the
most frequent symptom; this is often associated
with nausea, vomiting, and intermittent disten-
tion. In severe cases, acute surgical abdomen is
present. Fever, anorexia, and malaise are usually
absent; laboratory findings are nonspecific ex-
cept for mild eosinophilia in some cases. Radio-
logic examination is of little assistance in estab-
lishing a diagnosis other than if the obstruction
is complete or there is a perforation. Gastroin-
testinal series and small-bowel follow-through
may suggest a malabsorption syndrome with
coarse mucosal folds and dilated loops of small
intestine, but usually the proximal jejunum and
terminal ileum are normal. A careful review of
the case history as to previous potassium therapy
may be necessary to establish diagnosis.

CHARACTERISTIC ULCERS

The ulcers are characteristically circumferen-
tial, sharply delimited, and directly over the
zone of cicatricial narrowing. They are usually
solitary, sometimes double, rarely multiple and
are most commonly found in the lower ileum,
but also in the distal jejunum. The most impor-
tant distinguishing feature of the stenotic phase
is a band-like encirclement of the lumen by the
lesion which varies in size from several mm. to
several cm. In this phase, the segment of bowel
proximal to the lesion is dilated approximately
1 Vi to 2 times and has a thickened muscularis;
the distal segment is normal. The surrounding
mucosa and muscularis may show varying de-
grees of edema, hypertrophy and hemorrhagic
infiltration. The histologic picture depends upon
the severity and duration of the lesions. De-
tailed descriptions of clinical manifestations, gross
and histologic pathology, and therapy are given
elsewhere.41’ 42

There are two main concepts concerning the
mechanism by which potassium causes the le-
sions. The first is that potassium has a directly
injurious effect on the mucosa.3’ 23> 43 For ex-
ample, potassium chloride solution injected into
the intestine in concentrations similar to those ob-
tained from the release of enteric- coated tablets
containing potassium results in severe tonic con-
traction of the bowel, and an uncoated KC1 tab-
let placed directly on the intestinal mucosa causes

superficial necrosis by the time it is completely
dissolved.23 However, several types of evidence
lend greater support to the second concept that
the lesions are caused by an insufficiency of
blood to the affected part of the intestine.

RELEASE AND ABSORPTION

Briefly, Boley and co-workers postulate that
the precipitating factor is the rapid release of
potassium chloride and its absorption over a
short segment of intestine.22’ 34- 41> 42 The high
concentration causes spasm or paralysis of the
intramural and mesenteric vessels, predominant-
ly veins, with slowing of blood flow and subse-
quent infarction of varying severity. Circumfer-
ential ulceration, either superficial or deep, or
overt intestinal necrosis follows. Complete and
rapid clinical recovery may follow the mildest
degrees of injury. With greater damage, fibrosis
with increasing stenosis produces progressive in-
testinal obstruction. The most severe injuries pro-
duce perforation or intraluminal hemorrhage.

Evidence in support of the hypothesis that po-
tassium causes vascular insufficiency is from sev-
eral sources.

( 1 ) Mesenteric vascular insufficiency has been
implicated as a cause of segmental ulceration
and stenosis of the small bowel in conditions
other than those caused by potassium.22’ 44

(2) Histologic examination of tissue taken
from KC1 caused lesions in man and animals in-
dicates striking changes in mesenteric vessels,
particularly arteries and veins. Sections show the
lumens of vessels almost completely blocked with
a thickening of surrounding tissue.12’ 22> 41 Other
studies have not revealed mesenteric vascular
changes.3, 7’ 23> 45 Allen, et al41 recognize this
disparity in findings and discuss difficulties in ex-
amination of mesenteric tissue. They note that
they have had the opportunity to study adequate
sections of mesentery in man and animals.

VASCULAR INSUFFICIENCY

(3) Animal studies tend to be consistent with
the hypothesis that KC1 may result in a local
vascular insufficiency. Schwartz, et al22 occluded
the distal veins and arteries supplying the small
intestine of dogs by injection of microspheres into
the small branches of the superior mesenteric ves-
sels. They were able to reproduce the typical
ulceration with stenosis and dilatation complex
found in patients with intestinal ischemia. They
postulated that the role of potassium in the for-
mation of similar lesions was also primarily vas-
cular in nature.

JUNE 1970

323

POTASSIUM THERAPY / Emerson

Watson & Mark24 ligated arteries and veins
which supplied segments of the small intestine
of dogs. When 5 to 7.5 cm. of the small intestine
was rendered ischemic, changes occurred in the
bowel wall which were grossly and histologically
similar to those caused by the ingestion of en-
teric-coated KC1. If shorter segments were ren-
dered ischemic, collateral blood supply prevent-
ed significant changes in the bowel; if longer
segments were treated, hemorrhagic infarction
occurred. These observations lent further support
to the contentions that vascular lesions could
cause changes of this type in the bowel wall and
mucosa, and that it was not necessary to postulate
direct injurious effects of potassium on the mu-
cosa to explain the pathologic picture.

Myers, et al,53’ 54 have recently suggested that
the etiologic factor in stenosing ulceration is not
a specific toxicity of the potassium ion, but in-
volves the effect of local salt concentration. They
observed that hypertonic solutions of both NaCl
and KC1 produced gross and microscopic injury
similar to that seen in the early stages of pri-
mary non-specific small-bowel ulceration.

CARDIOVASCULAR PATIENTS

A high percentage of small intestinal lesions
associated with potassium chloride administration
are found in patients with some form of cardio-
vascular disease, although lesions have also oc-
curred in a number of patients without such dis-
ease. A condition of arteriosclerosis, for example,
might result in a critical reduction of blood flow
to the small bowel and set the stage for focal
infarction.

Mansfield, et al44 found that potassium chloride
tablets introduced into the distal part of the ileum
of the dog produced acute inflammatory changes
and occasional ulceration of the affected bowel.
When partial interruption of splanchnic blood
flow was accomplished by reducing the pressure
in the superior mesenteric and celiac arteries, the
magnitude of these drug-induced small bowel
changes was increased.

The authors conclude that their observations
support the clinical observations which indicate
that enteric-coated potassium chloride tablets
cause local inflammation or ulceration of the
small bowel, and that a reduction of the local
blood supply associated with vascular occlusive
disease may predispose the patient to this com-
plication. However, it must be noted that the
greater incidence of lesions in cardiovascular pa-

tients may simply reflect a larger number of
such patients on diuretic (and KC1) therapy. Fur-
thermore, small intestinal ulcerations have been
attributed to several causes other than vascular
insufficiency or KC1 administration.20’ 21> 44> 46

Boley, et al47 compared the effects of the chlo-
ride versus the citrate and the gluconate salts of
potassium using techniques similar to their previ-
ous study.34 Only minimal superficial changes
were found at the intestinal sites of potassium
citrate or gluconate; however, in five of six dogs
in which KC1 was implanted, a gross circumfer-
ential infarction was present at the site of the
salt, while all other sites of gluconate or citrate
implantation were normal. These results suggest
the relative safety of potassium citrate or gluco-
nate as compared to potassium chloride and con-
firm clinical observations (Table 1 ) that the organ-
ic salts of potassium are safer than KC1.

REPORTED CASES

Baker, et al3 reported 1 1 cases of small bowel
lesions out of an estimated 473 patients who re-
ceived hydrochlorothiazide plus potassium chlo-
ride in enteric-coated preparations, but no le-
sions in an estimated 331 patients who received
hydrochlorothiazide plus non-enteric potassium
preparations, among them 31 patients who re-
ceived potassium as the acetate, bicarbonate, and
citrate. Boley, et al47 speculate that since the
underlying etiology is the rapid absorption of
high concentrations of potassium over a short
length of intestine, the various potassium salts
may differ in their effect because of different
rates of absorption.

All of the potassium salts ionize almost im-
mediately and completely, but the absorption of
a cation across the intestinal wall is at least par-
tially controlled by the rate of absorption of the
respective anion. Absorption rates of ions such
as gluconate (large and monovalent), or citrate
(large and trivalent) are slower than that of the
smaller monovalent chloride ion. The slower ab-
sorption of these organic anions would help pre-
vent the rapid release of potassium over a short
segment of intestine and diminish the concen-
tration of potassium in the intestinal wall veins
at any one time.

THIAZIDE DIURETICS

Olive baboons were given two preparations of
thiazide diuretics containing KCk one consisted
of an outer coat of hydrochlorothiazide 25 mg.
surrounding an enteric-coated core containing

324

JOURNAL MSM A

572 mg. KC1; the second consisted of cyclopen-
thiazide 0.25 mg. in the outer shell with a wax
slow-release core containing 600 mg. KC1.45 The
enteric-coated KC1 produced lesions similar to
those reported in man; the slow release form
had no deleterious effects. The author suggested
that the slow-release form was safer.

Whether or not slow-release forms are safer is
open to question since Diener, et al37> 38 indi-
cated that gradual release tablets are more apt
to release sufficient KC1 in the stomach to cause
gastric irritation. Furthermore, studies on release
rates of various KC1 preparations48 indicate that
slow release forms would tend to place the KC1
in the stomach, while enteric-coated forms would
tend to release their contents in the small in-
testine. In fact, the main reason for the devel-
opment of enteric-coated tablets is to prevent re-
lease of certain types of medicines in the stom-
ach to avoid gastric irritation and to provide rapid
release in the small intestine,49’ 50 although there
was no evidence of sudden release and absorption
of one type of enteric-coated KC1 tablets.51

It appears that the relative safety of potas-
sium therapy is in terms of adequate dilution
such as provided by several liquid or effervescent
dosage forms, particularly of organic salts of po-
tassium.

SMALL-BOWEL LESIONS

Small-bowel lesions associated with enteric-
coated KCl-thiazide preparations are caused by
the KC1 component of the tablets. The lesions
are characteristically non-specific, circumferen-
tial, and consist of stenosis with or without ul-
ceration. The reported incidence is approximate-
ly 1/100,000 total hospital patients; probably
over 90 per cent of patients with typical lesions
have ingested potassium. Current evidence sup-
ports the primary vascular origin of the lesions
and suggests that chronic vascular insufficiency
predisposes the small bowel to injury by KC1.
The safest dosage forms of potassium are those
which have been diluted in an adequate amount
of water, particularly those which contain organic
potassium salts. ***

(47721)

REFERENCES

1. Watson, M.: Primary Non-Specific Ulceration of the
Small Bowel, A.M.A. Arch. Surg. 87:600, 1963.

2. Roberts, H.: Abdominal Distress After Taking Hy-
drochlorothiazide and Potassium, J. A.M.A. 178:965,
1961.

3. Baker, D.; Schrader, W.; and Hitchcock, C.: Small-
Bowel Ulceration Apparently Associated With Thi-

azide and Potassium Therapy, J. A.M.A. 190:586,

1964.

4. Lindholmer, B.; Nyman, E.; and Raf, L.: Nonspe-
cific Stenosing Ulceration of Small Bowel: Prelimi-
nary Report, Acta chir. scandinav. 128:310, 1964.

5. Lawrason, F.; Alpert, E.; Mohr, F.; and Mc-
Mahon, F. : Ulcerative-Obstructive Lesions of the
Small Intestine, J. A.M.A. 191:641, 1965.

6. Abbruzzese, A., and Gooding, C.: Reversible Small-
Bowel Obstruction: Withdrawal of Hydrochlorothi-
azide Potassium Chloride Therapy, J. A.M.A. 192:
781, 1965.

7. Ashby, W.; Humphreys, J.; and Smith, S. : Small-
Bowel Ulceration Induced by Potassium Chloride,
Brit. M. J. 2:1409, 1965.

8. Binns, T.; Pittman, A.; Burley, D.; and O’Brien, J.:
Iatrogenic Ulcers of the Small Intestine, Brit. M. J.
1:248, 1965.

9. Buchan, D., and Houston, C.: Small Bowel Ulcera-
tion Associated With Enteric-Coated Potassium
Chloride and Hydrochlorothiazide, Canad. M. A. I.
92:176, 1965.

10. Delaney, T., and Hoxworth, P.: Enteric-Coated Po-
tassium Chloride Enteropathy, Surg. Gynec. & Obst.
127:76, 1968.

11. Hartman, S.; Greaney, E.; and Rottapel, D.: Small-
Bowel Ulceration Due to Enteric-Coated Potassium
Ingestion in a Two-Year-Old Child, Surgery 61:814,
1967.

12. McDivitt, M.: Small-Bowel Ulcers With Thiazide
and Potassium, J. A.M.A. 191:679, 1965.

13. Payan, H., and Blaustein, A.: Potassium Chloride
and Small Bowel Perforation, Gastroenterology 18:
877, 1965.

14. Raf, L.: Potassium Chloride and Intestinal Ulcera-
tion, Lancet 2:593, 1965.

15. Reinus, F.; Weinberger, H.; and Fischer, W.: Medi-
cation-Induced Ulceration of the Small Bowel, Am.
J. Surg. 112:97, 1966.

16. Richardson, J.: Potassium Chloride and Intestinal
Ulceration, Lancet 2:593, 1965.

17. Roberts, H.: Potassium Chloride and Intestinal Ul-
ceration, Lancet 2:1127, 1965.

18. Rosen, R., and Borucki, D.: Small-Bowel Ulcers
With Thiazide and Potassium, J. A.M.A. 191:419,

1965.

19. Withers, J.; Cooper, J.; and Rosen, A.: Delayed
Enteric-Coated Potassium Ulcerative Obstruction of
Small Intestine, Rocky Mountain M. J. 64:63, 1967.

20. Anderson, M.; Drake, C.; and Beal, J.: Segmental
Ulceration of the Small Intestine, Am. J. Surg. Ill:
120, 1966.

21. Kiser, J.: Focal Lesions of the Small Intestine, Am.

I. Surg. 1 12:48, 1966.

22. Schwartz, S.; Boley, S.; Allen, A.; Schultz, L.;
Siew, F.; Krieger, H.; and Elguezabal, A.: Some As-
pects of Vascular Disease of the Small Intestine,
Radiology 84:616, 1965.

23. Morgenstern, L.; Freilich, M.; and Panish, J.: The
Circumferential Small-Bowel Ulcer: Clinical Aspects
in 17 Patients, J. A.M.A. 191:637, 1965.

24. Watson, M.; and Mark, J.: Ulceration of the Small
Intestine Relation to Enteric-Coated Potassium, Am.

J. Surg. 112:421, 1966.

25. Warr, O., and Nash, J.: Jejunal Ulceration: Report
of a Case Apparently Associated With Potassium
Gluconate, J.A.M.A. 199:217, 1967.

26. Iatrogenic Ulcers, J.A.M.A. 190:681, 1964.

27. Iatrogenic Ulcers of the Small Intestine, Brit. M. J.
2:1611, 1964.

28. Small Bowel Ulceration and Enteric-Coated Potas-
sium Chloride-Thiazide Medication, Canad. M. A. J.
92:188, 1965.

29. Small-Bowel Ulceration: In Pursuit of an Etiology,
J.A.M.A. 191:668, 1965.

30. Bowel-Ulcer Survey Acquits Diuretics: FDA-En-

JUNE 1970

325

POTASSIUM THERAPY / Emerson

dorsed Global Investigation by Two Drug Firms
Shifts Suspicion to Potassium as Cause of Stenosing
Lesions, M. World News 6:32, 1965.

31. McMahon. F.: Potassium Salts and Intestinal Ulcer,
J.A.M.A, 195:977, 1966.

32. Snively, W. : Potassium Salts and Intestinal Ulcer,
J.A.M.A. 195:977, 1966.

33. Allen, A.; Baker, D.; Boley, S.; Goldner, M.; Pan-
ish. J.; Russell, R.: Schrader, W.; and Schwartz, S.:
Central Registry for Small-Bowel Ulcers, J.A.M.A.
190:1015, 1964.

34. Boley, S.; Schultz, L; Krieger, H.; Schwartz, S.;
Elguezabal, A.; and Allen, A.: Experimental Evalu-
ation of Thiazides and Potassium as a Cause of
Small-Bowel Ulcer, J.A.M.A. 192:763, 1965.

35. Potassium Salt Preparations Intended for Use by
Man, Federal Register 30:5790, April 24; 30:6071,
April 29, 1965. Code of Federal Regulations, Title
21, Section 3.15.

36. Certain Combination Drugs Containing Thiazides
and Potassium Chloride or Thiazides, Potassium
Chloride, and Reserpine or Rauwolfia Serpentina,
Federal Register 34:14089, Sept. 5, 1969.

37. Diener, R.; Shoffstall, D.; Earl, A.; and Gaunt, R.:
The Production of Potassium-Induced Gastrointesti-
nal Lesions in Monkeys, Fed. Proc. 24:714, 1965.

38. Diener, R.; Shoffstall, D.; and Earl, A.: Production
of Potassium-Induced Gastrointestinal Lesions in
Monkeys, Toxicol. Appl. Pharmacol. 7:746, 1965.

39. Bokelman, D.; Bagdon, W.; Zwickey, R.; and Mat-
tis, P.: Ulcerogenic Effect of Potassium Chloride on
the Gastrointestinal Tract of the Monkey, Fed.
Proc. 24:715, 1965.

40. Stahlgren, L.; Sapena, A.; and Roy, R.: Ulcerogenic
Properties in Enteric Coated Compounds in Dogs,
Surgical Forum 16:367, 1965.

41. Allen, A.; Boley, S.; Schultz, L.; and Schwartz, S.:
Potassium-Induced Lesions of the Small Bowel,
J.A.M.A. 193:1001, 1965.

42. Boley, S.; Allen, A.; Schultz, L.; and Schwartz, S.:

Potassium-Induced Lesions of the Small Bowel. I.
Clinical Aspects, J.A.M.A. 193:997, 1965.

43. Lindholmer, B., and Raf, L.: Nonspecific Stenosing
Ulceration of the Small Intestine, Acta chir.
scandinav. 129:434, 1965.

44. Mansfield, J.; Schoenfeld, F.; Suwa, M.; Geur-
kink, R.; and Anderson, M.: Role of Vascular Insuf-
ficiency in Drug-Induced Small Bowel Ulceration,
Am. J. Surg. 113:608, 1967.

45. Lister, R. : Potassium Chloride and Intestinal Ulcer-
ation, Lancet 2:794, 1965.

46. Teicher, I.; Arlen, M.; Muehlbauer, M.; and Al-
len, A.: The Clinical Pathological Spectrum of Pri-
mary Ulcers of the Small Intestine, Surg. Gynecol.
& Obstet. 116:196, 1963.

47. Boley, S.; Schultz, L.; Schwartz, S.; Katz, A.; and
Allen, A.: Potassium Citrate and Potassium Gluco-
nate vs. Potassium Chloride. Experimental Evalua-
tion of Relative Intestinal Toxicity. J.A.M.A. 199:
215, 1967.

48. Barlow, C.: Release of Potassium Chloride From
Tablets, J. Pharm. & Pharmacol. 17:822, 1965.

49. Wynn, V., and Landon, J.: The Alimentary Absorp-
tion of Some Enteric-Coated Sodium and Potassium
Chloride Tablets, J. Pharm. & Pharmacol. 15:123,
1963.

50. Lachman, L.; Barrett, W.; Rinehart, R.; and Shep-
pard, H. : The In-Vivo Effectiveness of Enteric-Film
Coatings Applied to Hydrochlorothiazide-Potassium
Chloride Tablets by a Programmed Automated
Coating Process, Current Therap. Res. 6:491, 1964.

51. Jouhar, A.; Garnett, E.; and Wallington, J.: Potas-
sium Absorption — A Comparison of In Vitro and
In Vivo Studies, J. Pharmaceut. Sci. 57:617, 1968.

52. Rosenstein, G., and Belton, E. : The Relation of Po-
tassium Therapy to Small-Bowel Ulcerations, Med.
Ann. District of Columbia 38:539, 1969.

53. Myers, R.; Brown, C.; and Deaver, J.: In Vivo Ef-
fect of Potassium on the Small Bowel, Ann. Surg.
166:693, 1967.

54. Myers, R.; Deaver, J.; and Brown, C.: In Vivo Ef-
fects of Potassium in Relation to Stenosing Ulcera-
tion of the Small Bowel, Am. J. Gastroenterol. 52:
353, 1969.

SWINGING GRANDMA

“What Grandma needs,” someone said at the supper table, “is
some real warm weather if she’s going to get relief from her
rheumatism.”

Johnny listened carefully and remembered to include her in
his prayer that night, saying, “Lord, please make it hot for
Grandma.”

326

JOURNAL MSM A

Seminar on Care of the Newborn— I

Recent Advances
in Newborn Care

ALFRED W. BRANN, JR., M.D.

Jackson, Mississippi

Mississippi today faces a most serious health
problem in its high infant mortality rate. The
scope of this problem is extremely far reaching
as regards the number of lives lost each year and
the high incidence of central nervous system dam-
age occurring in prematurely born infants and in
infants who have had serious disease in the neo-
natal period. The economic aspects, both from
the standpoint of prolonged costly care of the
mentally retarded person and the loss in econom-
ic productivity of these citizens, are equally over-
whelming, to say nothing of the grief and disap-
pointment to the family of a retarded child. Thus,
from both a health and an economic point of
view, the state could profit by reducing the in-
fant mortality and morbidity.

A review of the infant mortality data for Mis-
sissippi and its comparison with other southern
states and the United States, helps to give some
perspective to the problem. (Figure 1 is a
graph reproduced from the Vital Statistics of
Mississippi, 1967.) This graph depicts the in-
fant mortality by race from 1920 to 1967. The
State Board of Health analyzes this graph as
follows: “There were 1,645 deaths of infants un-
der one year of age in 1967; this total was 211
less than in the previous year and the smallest
ever recorded in Mississippi. The infant death

From the Department of Pediatrics, University of Mis-
sissippi School of Medicine, Jackson, Miss.

rate of 35.3 per thousand live births was also the
smallest on record and may indicate a downward
trend after about 20 years during which there was
no improvement. Both race groups experienced
declines, but that for the non-whites was con-
siderably larger.

Recent developments in care of the new-
born have the objective of reducing Missis-
sippi’s infant mortality rate. This article is
first of a six month series designed to bring
the newest diagnostic and treatment meth-
ods to the physician in the local community
hospital. The series is edited by Dr. Alfred
W . Brann, Jr., of the University of Missis-
sippi School of Medicine. He and the au-
thors will be glad to respond to readers’
questions.

“The accompanying graph of infant mortality
by race clearly illustrates the lack of progress in
bettering infant health since 1946. The line for
the whites shows that although improvement con-
tinued at a slower pace until 1955, there has
been very little change since then. The curve
for the non-whites shows an even worse situation,
an upward trend from 1946 through 1965; how-
ever, the unusual drop in 1967 is a hopeful sign.”

JUNE 1970

327

NEWBORN CARE /Brown

“Even though Mississippi’s infant death rate
in 1967 was the lowest in its history, it was still
the highest in the United States, exceeding the
national rate by 58 per cent and that for South
Carolina which had the next highest rate in the
South, by 28 per cent. Moreover, Mississippi’s
race specific rates were also higher than the cor-
responding national figures, that for whites 16
per cent higher and that for non-whites 32 per
cent higher.”

Another interesting statistic in the breakdown
of the infant mortality is that there are more
deaths in the first year of life than there are in
the next thirty years of life exclusive of the first
year. A statistic which is a bit more pertinent to
the over-all thrust to encourage an upgrading of
neonatal care, is the fact that two-thirds of the
deaths in the first year of life occur in the first
month of life and most of these deaths are in the

Vital Statistics
Mississippi - 1967

first three days of life. In the total over-view of i
the United States in its relationship with other na-
tions, it is also interesting that the U. S. ranks
below some 15 other countries in its over-all in-
fant mortality rate. Although infant mortality is
of major consideration, infant morbidity, partic-
ularly as it relates to brain damage that is so
frequent, must also be dealt with.

However, the encouraging point, as all of these
statistics are viewed, is the fact that there are
areas in the world and areas in this country and
indeed in this state that have very low infant
mortality rates, comparable to the lowest rates in
the world. This fact alone gives indication that
the available information and the environmental
setting can be achieved to reduce infant mortal-
ity and morbidity, if the “tools” and “know-how”
are properly applied.

There have been many recent developments
in the understanding of the physiological proc-

328

JOURNAL MSM A

TABLE 1

DANGER SIGNS IN THE NEWBORN*

A. C ardio-Respiratory System
Difficult or rapid (>60) respirations
Rapid (>160), slow or irregular pulse
Cough

Cyanosis

Apnea

B. Nervous System
Abnormal cry
Full fontanelle

Abnormal head size (normal 31-37m.)

Convulsions

Jitteriness

Excessive irritability
Hypotonia
Lethargy
Paralysis

C. Orthopedics
Incomplete hip abduction

D. G astro-intestinal System
Excessive salivation
Vomiting bile

No meconium stool in 48 hours
Abdominal distention
Abdominal mass

E. Genito-Urinary System
No urine in 24 hours
Dribbling urine
Ambiguous genitalia

F. Hemopoietic System
Jaundice
Petechiae

Bleeding from cord or circumcision

G. Miscellaneous

Any congenital malformation
Single umbilical artery
Abnormal facies
Cord odor or exudate
Fever or hypothermia

Change in behavior or condition (not looking right)

* Modified from a chart of the Newborn Center, Denver Children’s Hospital.

esses that take place when the fullterm infant be-
comes a newborn.1 Advances have been made
in the detection as well as the understanding of
diseases that are produced when deranged phys-
iology occurs following a difficult or abnormal
birth. Care has improved for the critically ill
newborn ranging from simple measures to very
complicated intensive care centers especially de-
signed for the neonate.

INFORMATIVE STUDIES

The usefulness of this new information is
readily apparent when data from the Collaborative
Perinatal Study sponsored by the National Insti-
tutes of Health — National Institutes of Neuro-
logical Disease and Stroke is reviewed. This
study2 revealed that in infants whose condition
was excellent at birth that the percentage of
neurological deficit was in the range of 1.4 per
cent. In infants who were depressed at birth, even
though they were fullterm infants, there was a
steadily increasing rate of neurological deficit in
those patients who were more depressed.

From both human data and experimental ani-
mal data, there are certain biochemical and phys-
iological abnormalities that may occur in utero,
during birth, or in the immediate postnatal peri-
od which are closely associated with brain dam-
age. These are all potentially treatable conditions

through good medical and nursing detection and
therapy. These conditions are hypoxia, acidosis,
hypoglycemia, hyperbilirubinemia, hypocalcemia,
hyponatremia, hypernatremia, hypothermia, and
hypotension. In addition to these biochemical
and physiological abnormalities, infection also
plays a great role in producing much of the
brain damage seen in the neonatal period.

Many diseases that present themselves in the
newborn period have their onset in utero. Al-
though it would be much better to attack the
problem of the in utero patient and prevent the
disease process in the newborn, many times
the infant who may get into difficulty cannot be
predicted. Thus until more refined methods of
detecting fetal abnormalities are available, the
sick neonate will have to be dealt with in the
best possible fashion.

Although the term, intensive care, has pri-
marily been used around large medical centers,
it is felt that this term and concept as regards the
newborn must be carried to the local community
hospital, where most of the sick newborns are
cared for. Although most hospitals cannot pro-
vide extremely specialized care, they can and
some do have the needed equipment for resusci-
tation of the newborn, for regulation of tem-
perature, for oxygen administration and moni-
toring, and for laboratory techniques that will
permit detection of the above mentioned abnor-

JUNE 1970

329

NEWBORN CARE /Brown

malities. A very significant phase in the correc-
tion of some of these biochemical abnormalities
is the recognition of disease, which in the new-
born, can be more difficult than in the older child
or adult. If these signs and symptoms are recog-
nized and correctly diagnosed, many of the prob-
lems in the newborn period can be cared for at
the local community hospital. However, at times
there is a need for referral to a neonatal intensive
care center that can care for complicated medical
and surgical problems.

Two approaches have been found to be use-
ful in recognition of disease in the newborn peri-
od. First, it is known now from experience that
certain babies can be identified in utero or im-
mediately at birth as having a greater chance of
developing difficulties than other babies. In this
case, these babies should be earmarked and ob-
served more closely for signs and symptoms of
disease. Second, there are certain signs and symp-
toms that may develop in the first three to four
days of life in the newborn infant which have
consistently been associated with a distressed
sick neonate. When both of these alerting sys-
tems are used, the index of suspicion and recog-
nition of disease increases. The two alerting sys-
tems, Infants at Potential Risk and Danger Signs
in the Newborn (Tables 1 and 2), are listed be-
low.

TABLE 2

INFANTS AT POTENTIAL RISK

Infant of diabetic mother
Infant of toxemic mother
Infant of mother with fever
Infant of Rh negative mother
Infant of O mother
Ruptured BOW for 24 hours
Third trimester bleeder
Difficult labor or delivery
C-section delivery
Apgar less than 7

Abnormal birth weight for gestational age
Premature infant
Multiple births

Since there have been so many changes in
newborn care, and since so many of these de-
velopments are applicable to the care of the new-
born in the local community hospital where, as
stated above, most of the sick newborns are
cared for, a series of articles has been designed

to bring some of this information to the readers
of this journal. The title of this series of articles
will be “Seminar on Care of the Newborn.” The
series will attempt to correlate the new advances
in diagnosis and care with the above listed alert-
ing signs. As presently designed, these articles
will run some six months and will cover prob-
lems that have seemed to be most frequently re-
curring in the newborn period.

FUTURE TOPICS

The initial article will deal with causes of a
depressed infant at birth and methods of resus-
citation in the newborn period, with very specific
recommendations for equipment needed in the
labor and delivery room together with recom-
mendations for specific methods in drugs for re-
suscitation. The second paper will cover in-
fections in the newborn period. It will include
septicemia, meningitis, pneumonia, and diarrhea,
the most common infections in the first month
of life. Clinical manifestations, diagnostic proce-
dures, and antibiotic therapy will be discussed.

The third article will deal with hematological
problems in the newborn specifically, jaundice,
anemia, and hemorrhagic disease of the newborn.
Comments regarding therapy for hyperbilirubine-
mia, such as exchange transfusion and photo-
therapy will be discussed. The fourth paper in
the series will deal with surgical emergencies oc-
curring in the newborn.

The fifth article will deal with central nervous
system disease in the newborn period. This topic
will include a discussion of neonatal seizures,
anoxia, bilirubin toxicity to the central system,
congenital malformations and brachial plexus
palsy. The sixth article in the series will discuss
endocrine and metabolic diseases that affect the
newborn, as well as other congenital and ac-
quired metabolic diseases.

The series of articles, as stated above, is pri-
marily oriented toward discussion of recent ad-
vances in newborn care as they most directly
apply to the local community hospital. If there
are any specific topics that would better serve
this end, suggestions can be sent to the author
for consideration in this series of articles. ***

2500 North State St. (39216)

REFERENCES

1. James, L. Stanley: Scientific Basis for Current Peri-
natal Care, Arch. Dis. Childh. 42:457-466, 1967.

2. Druge, J.; Kennedy, C.; Berendes, H.; Schwarz, B. K.;
and Weiss, W.: The Apgar Score as an Index of In-
fant Morbidity, Develop. Med. Child. Neurol. 8:141,
1966.

330

JOURNAL MSMA

Radiologic Seminar XCVI
Reversible Vascular Occlusion

of the Colon

C. D. BOUCHILLON, M.D.

Laurel, Mississippi

Reversible vascular occlusion of the colon is
a roentgenologic and clinical entity. Clinical and
experimental evidence indicate that its manifesta-
tions may subside without sequelae and unneces-
sary surgery may be avoided by prompt recog-
nition.

When the blood supply to the colon is com-
promised as a result of changes in the vascula-
ture due to local lesions (thrombosis, embolism)
or secondary to remote causes (shock, conges-
tive heart failure, hemorrhage), ischemic dam-
age may occur.

Marston et al have divided ischemic colitis into
three clinical patterns (a) transient ischemic co-
litis (b) ischemic stricture (c) gangrene of the
colon. The patterns correspond to the degree of
vascular insufficiency, either arterial or venous.
Minor insufficiency causes transient reversible co-
litis, moderate ischemia produces mucosal and
some deeper damage and results in some stric-
ture formation, and severe ischemia results in ir-
reversible gangrene.

A decade ago the more severe disease was
emphasized, but we now know that the milder
forms are much more common. Our emphasis
here is on the reversible form of the disease.
Clinically, the symptoms vary considerably, but
typically they present in an elderly arterioscle-
rotic man with abdominal pain, usually some

Sponsored by the Mississippi Radiological Society.
From the Department of Radiology, Jones County Com-
munity Hospital.

Figure 1 — 2.20.65. Barium enema examination
shows the eight cm. area of irregular thickening of
the wall of the mid descending colon. Typical
“thumbprinting,” or pseudotumor indentations (ar-
rows) are due to submucosal hemorrhage. Ulceration
is not evident, and could not be expected at this early
stage of ischemia.

33 1

JUNE 1970

RADIOLOGIC SEMINAR / Bouchillon

diarrhea, rectal bleeding, and abdominal tender-
ness. The presence, of course, of an abdominal
aneurysm or history of aortic graft would par-
ticularly suggest the diagnosis.

The sequence of events in reversible vascular
occlusion is (a) submucosal hemorrhage with as-
sociated intraluminal bleeding and appearance on
barium enema study of thickening of the wall
locally, so-called thumbprinting or pseudotumor
appearance and intermittent spasm, (b) grad-
ual subsidence of the hemorrhages and pericolic
fat inflammation with improvement of the thick-
ened wall on the radiograph, (c) development
of superficial ulceration, (d) healing with or with-
out narrowing of the colon.

CASE PRESENTATION

Case presentation: Mr. G. W., age 70, ar-
teriosclerotic, presented with two hours’ onset
of cramping abdominal pain in the left abdomen,
vomiting, left abdominal tenderness, and mild
leukocytosis. Six hours later he developed bloody
diarrhea. Clinical impression was diverticulitis.

Figure 2. Spot films made on the above examina-
tion reveal the slight change in the caliber of the
lumen, indicating that intermittent spasm is also
present.

A barium enema examination twenty-four
hours after onset of symptoms revealed typical
findings of localized colon ischemia with irregu-
lar thickening and edematous appearance of the
wall of the mid descending colon, with pseudo-
tumor formation, “thumbprinting” indentations,
plus intermittent spasm.

He responded rapidly to supportive measures
plus antibiotics, and was asymptomatic two weeks

later. A follow-up colon examination five weeks
after the original one revealed the colon to ap-
pear entirely normal. Also, three subsequent co-
lon examinations during the next three years
were negative with no sign of stricture formation.

Figure 3. Follow-up examination five weeks later,
and two weeks after the symptoms cleared , reveals
the descending colon to now appear entirely normal.

The differential diagnoses to be entertained
from the roentgen appearance on the initial study
are principally intramural tumor, lipomatosis,
pneumatosis coli, and juxtacolonic inflammatory
disease.

Abdominal angiography is rarely helpful here
as this is a disease of the small vessels.

Some pertinent points are:

1. The appearance of the lesion on x-ray will
vary with the stage of the disease, but the impor-
tant point is that it continued to improve on sub-
sequent colon examinations performed during the
next few weeks.

2. The ulcerations are superficial and difficult
to visualize on the film. On any one study they

332

JOURNAL MSM A

REFERENCES

might resemble any other form of localized ul-
ceration. Indeed, some investigators believe
chronic intermittent ischemia plays a major role
in the etiology of chronic ulcerative colitis, the
basis of the ischemia being a variety of factors
including allergic and psychogenic phenomena.
In reversible ischemia, however, the improvement
is fast and the colon is typically normal in four
to six weeks. Later, stricture may develop, and
follow-up examinations are in order.

3. It must be emphasized that the course of
the vascular occlusion of the colon cannot be
predicted on the initial roentgen examination.
These findings must be correlated with the clin-
ical course. If symptoms persist, surgical inter-
vention is indicated, for two reasons: either the
diagnosis of vascular occlusion is wrong, or the
viability of the involved bowel is uncertain.

Jones County Community Hospital (39440)

1. Miller, W. T., Scott, J., Rosato, E. F., Rosato, F. E.

and Crow, H.: Ischemic Colitis with Gangrene,

Radiol. 94:291-297 (Feb.) 1970.

2. Marston, A.: Patterns of Intestinal Ischemia, Ann.
Roy, Surg. (England) 35:151-181, 1964.

3. Schwartz, S., Boley, S. S., Robinson, K., Krieger, H.,
Schultz, L. and Allen, A. C.: Roentgenologic Features
of Vascular Disorders of the Intestines, Radiol. Clin.
N. Amer. 2:71-87, 1964.

4. Smith. R. F. and Szilagy, D. E.: Ischemia of the
Colon as a Complication of the Surgery of the Ab-
dominal Aorta, Arch, Surg. 80:806-821, 1960.

5. Marshak, R. H., Maklansky, O. and Calem, S. H.:
Segmental Infarction of the Colon, Amer. J. Digest.
Dis. 10:86-92, 1965.

6. Farman, Betancourt, and Kilpatrick: The Radiology
of Ischemic Proctitis, Radiology 91:302-307 (August)
1968.

7. Schwartz, Boley, Lash, and Sternhill: Roentgenologic
Aspects of Reversible Vascular Occlusion of the
Colon and Its Relationship to Ulcerative Colitis.
Radiology 80:625-635 (April) 1963.

8. Kittredge, Richard D.; Ischemia of the Bowel, A.M.
Journal of Roentgenology, Radium Therapy and
Nuclear Medicine 103:400-404 (June) 1968.

THE HIGH AND THE DIDIE

The lodge brothers filed out 10 minutes after they’d entered.
“What’s wrong?,” a late arrival gasped.

“No leader,” replied a brother sadly. “Our Grand, All-Power-
ful, Invincible, Most Supreme, Courageous, Unconquerable Po-
tentate had to stay home and baby-sit.”

JUNE 1970

333

The President Speaking

‘Changes and Challenge’

PAUL B. BRUMBY, M D. ,
Lexington, Mississippi

For the 102nd time the physicians of Mississippi assembled
recently at Biloxi for study and to learn of the recent advances
in medical science and practice.

Great changes have occurred even in our own assembly since
the passage and implementation of Public Law 89-97. This is
the law that has given us Medicare and Medicaid and also prom-
ised quality health care without limit as a right, and not a privi-
lege to be earned. Medical care by definition was changed to
health care, and health itself was defined as a state of physical,
mental, and social well-being. This health care is to be given in a
dignified manner acceptable to the patient and must be furnished
with reverence.

This is the concept that has given us Mound Bayou, Marks,
CHIP, Fayette and the projected Milton Olive and South Delta
projects with their clinics and famous outreach programs previ-
ously staffed by persons from outside the South. The addition of
social well-being to the definition of medical care is a concept
with which we must live.

However, the most pressing demand to be met in our gov-
ernment programs is the policing of our own ranks. Competent
and fair peer review offers the only solution which can prevent
office and hospital audits, and more of the arbitrary decisions
by the independent fiscal agents of various programs. Too, peer
review committees will be most useful in combatting our own
HB 407 which would legally establish the doctrine of res ipsa
loquitur to the great detriment of our members and the great,
great increase in our malpractice insurance costs. I quickly add
that our present low insurance rates are the result of the efforts
of our society.

Our patients know that we are serving them with a singular
devotion. In return, we have their deep appreciation and devo-
tion in spite of our growing negative image which is being creat-
ed by the press and others outside our ranks. ***

334

JOURNAL MSMA

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 6

JUNE 1970

Abortion and the Law:
Anachronisms Racing Science

l

The Supreme Court of the United States has
agreed to review the decision of the federal trial
court in striking down the District of Columbia
abortion law. The decision, expected in the fall
of this year, may well write the last chapter in
the debate which had encompassed medical, re-
ligious, academic, and legal groups. And the
odds are that most restrictions against therapeu-
tic abortion on state statute books will become
invalid.

The view is popularly held that prohibitions
against abortion proceed primarily from moral
bases. It is true that major religious bodies have
assumed moral and theological positions on this
question. The Catholic Church opposes abortion
per se, while most Protestant denominations are
either liberal or accept a limited policy toward
the procedure.

The Orthodox Jewish faith is said to permit
abortion only to save the mother’s life, while the
Reformed faith is less restrictive. The American
Medical Association made its first new utterance
on the subject in more than 70 years at the At-
lantic City annual convention in 1967. A minor-
ity of the states have revised their statutes. The
debate continues, but the issue may soon be re-

solved, at least from a legal point of view. What
remains to be answered is the translation of the
resolution into clinical practice. This is a matter
far from resolution.

II

Within the past three years, 10 states have
modified their abortion laws along the lines rec-
ommended by the American Law Institute.
These are Arkansas, California, Colorado, Dela-
ware, Georgia, Kansas, Maryland, New Mexico,
North Carolina, and Oregon.

In 1966, the Mississippi statutes were amend-
ed to permit abortion when the pregnancy results
from forcible rape. Hawaii was the first state to
enact an “on-demand” abortion law, requiring
only that the fetus be nonviable, that the patient
be a resident of the state for 90 days, and that
the procedure be undertaken only by a licensed
physician in a licensed hospital.

A similar law enacted in Maryland was ve-
toed by the governor, but an on-demand measure
was signed by New York's Nelson Rockefeller.

In three states, constitutional tests of abortion
laws have gone to the state supreme courts. The
California tribunal swept aside its ancient statute
authorizing abortion only to preserve the moth-
er’s life as unconstitutional because of vagueness

JUNE 1970

335

EDITORIALS / Continued

and uncertainty of intent. What could have been
the landmark ruling failed, however, because the
U. S. Supreme Court declined to review the de-
cision.

The Massachusetts Supreme Court upheld the
constitutionality of the state’s antiabortion law
against charges of vagueness similar to those
brought in California. But the key case was U. S.
v. Vuitch in the District of Columbia. The fed-
eral district court declared the statute unconsti-
tutional on the basis of its being vague. While it
is not clear why the U. S. Supreme Court ac-
cepted the D. C. appeal while declining Califor-
nia’s it may be that the D. C. statute is more
nearly representative of most states in that it per-
mits abortion only “when it is necessary to pre-
serve the mother’s life or health.’’

Mississippi’s law, sponsored, incidentally by
the state medical association in 1952 as a crim-
inal law, permits therapeutic abortion only to
save the mother’s life. The issue 18 years ago
was not liberalizing the law but putting teeth in
it against illicit abortions. Even as amended in
1966, the Mississippi statute is one of the most
archaic and conservative.

The association’s new position, a result of
adoption of Resolution No. 2 at the 102nd An-
nual Session, would extend the circumstances un-
der which the procedure may be undertaken.

Ill

The most ancient civilizations practiced abor-
tion. Hippocrates mentions it in the oath, where
he pledges not to give a woman an instrument
to produce abortion. Until the 19th century,
abortion during early months of pregnancy was
not prohibited by law in any nation in the
world. The first such law was enacted in England
in 1803, and the first statute in the United States
was passed by the Illinois legislature in 1827.
But the first state to proscribe therapeutic abor-
tion as such was New York in 1829.

From that point on, the idea caught on, and
by 1875, virtually every state had enacted some
sort of antiabortion law. But the objectives ap-
peared to be more medical than legal, because
our forefathers were not so preoccupied with
abortion as they were with the consequences. The
New Jersey Supreme Court, in an 1848 decision,
ruled that the purpose of the state’s abortion
law “was not to prevent the procuring of abor-
tions so much as to guard the health and life of
the mother against the consequences of such at-
tempts.” There are valid questions in the minds

of many legal authorities if there were really a j
moral intent in most of the state laws.

But the science of medicine leaped far ahead
of the laws which regulate it. The safety of the
procedure in the proper clinical environment is
well-established. New knowledge has entered the
picture, and medical reasons for abortion have
changed almost completely.

IV

The picture on criminal or illicit abortions in
the United States is cloudy, too. Estimates of
“experts” vary from 10,000 such procedures
each year to more than a million. One legal au-
thority noted these extreme variations and said
wryly that “when the data vary by 600 per cent,
you do not know the answer.”

One effect of the ancient state laws, however,
is much more susceptible to valid statistical
analysis. Under our restrictive laws, white mid-
dle-class women have, by far, the greatest num-
ber of therapeutic abortions. In one study in
New York City, the ratio of therapeutic abor-
tions to term births in private hospitals was
1:1,250, while the ratio in municipal and char-
ity hospitals was 1:20,000.

A few authorities have speculated that fail-
ure of civilization to employ contraception ef-
fectively and to withhold liberalization of abor-
tion laws might result in the denial of the free-
dom to have more than a prescribed number of
children. This is a dismal prospect, although we
are finding out every day we live that Malthus
was correct when he said that the population
would outgrow the food supply.

Medicine’s position is moderate on abortion,
believing that it should be undertaken to pre-
serve life or health of the mother, when the
pregnancy results from rape or incest, or when
there is a probability that the child will be born
deformed. This is generally the objective in lib-
eralizing state laws — to arrive at this legal pos-
ture. But the Hawaii law and the Vuitch case may
change all of this, and the law may jump ahead
of the science to create new problems. — R.B.K.

The CBS Eye:
Color It Yellow

The color trademarks of NBC and ABC are
respectively a peacock and a red-white-and-blue
monogram. After “The Promise and the Practice”
and “Don’t Get Sick in America,” we have a sug-
gestion for CBS: Be sure to get enough yellow

336

JOURNAL MSM A

in that video orb to portray accurately the net-
work’s jaundice against American medicine.

The two hour-long documentaries were edi-
torials, pure and simple. The viewpoint was
clear: CBS is all-out for national compulsory
health insurance, closed panel practice, reorga-
nization of care, and about everything else anti-
establishment to medicine. Regrettably, networks
are not subject to Federal Communications
Commission proscriptions about program content
— at least not yet. The law on equal time, good
taste, and that sort of thing applies to the li-
censees or the TV stations. The networks, then,
are the wholesalers.

It is disappointing to see Mississippi television
stations broadcast this sort of distorted, lop-sided,
slanted airfare with nary a word to the public
about hearing the other side. It has long been
established that CBS and NBC are antimedicine,
because in 1962 when the celebrated Madison
Square Garden speech by the late President Ken-
nedy was carried, only ABC would give medi-
cine equal prime time.

This brings to mind the classic statement by
Leo E. Brown, a senior AMA executive, who
noted in 1962, after CBS had filmed extensive
footage of then-President Leonard Larson which
was never put on the air, that “the truth about
American medicine lies on a CBS cutting room
floor.”

This recent distortion which was an assault is
destructive, not constructive. There were no pos-
itive suggestions, only dispair, inequity, fee-slug-
ging, waiting lines, and inaccessible hospitals.
Slander and untruth hurt their victims, and medi-
cine was hurt by this CBS onslaught. It seems
to be part of the pattern, but medicine will tell
its story if it be door-to-door, patient-to-patient,
and state-by-state. And the day is fast dawning
when the airwaves will be cleaned up one way
or the other, more than likely station-by-station,
and make the television entrepreneurs observe
the law. — R.B.K.

Goods and Services
Simply Cost More

The cost of medical care? Yes, it is substan-
tial, particularly hospital care. Other cost com-
ponents in total health services behave astonish-
ingly like other goods and services which we must
purchase. An interesting comparison was pub-
lished by the authoritative and objective U. S.
News and World Report.

Says the noted weekly: Hospital costs lead

the upward spiral with operating room charges
up 67 per cent and semiprivate rooms up 86 per
cent. The time base is 1965, and the survey
covers five years through January 1970.

Auto insurance went up 38 per cent in this
period, and mortgage insurance, 38 per cent.
Household workers (the magazine did not say
how to get one) had wage increases of about
45 per cent, and haircuts were up 33 per cent.

In the same five-year period, physicians’ fees
were reported to have been increased about 38
per cent and dentists’ fees were up just over 30
per cent.

While USNWR did not analyze the trend in
depth, it should be apparent that those who pro-
vide professional services must also purchase
goods and services themselves. Not just as con-
sumers, mind you, but as necessary prerequisites
to operating their practices. The physician is
paying more for his nurse, his secretary, his pro-
fessional premises, and virtually everything im-
plicit in his practice.

American medicine is acutely aware of the
cost picture in providing health services. Every
medical organization worthy of its name has
pledged to provide the best care consistent with
conservation of the health care dollar. We need
to concentrate on this problem, because as Dr.
James L. Royals, 1969-70 president, said in his
recent address, “The cost of health care is rap-
idly becoming unacceptable to the public.”

Obviously, no sugar-coated explanation makes
more palatable spending money for something
you don’t want in the first place, illness or in-
jury. Such outlays are usually unplanned, too,
and health care expenditures often deny us some-
thing we would much rather have. After all, who
wouldn’t, at this season of the year, rather buy
a new outboard motor than have his gallblad-
der out?

But we do need to communicate and safe-
guard. This is the positive story which needs
telling. — R.B.K.

Dempsey T. Amacker of Natchez has been
named to Emory University’s Committee of One
Hundred. The Committee is composed of prom-
inent Methodist laymen in the Southeast who
have a special interest in ministerial education.

Thomasina Blissard of Jackson was featured
speaker at Belhaven College’s alumni luncheon

JUNE 1970

337

PERSONALS / Continued

on May 2. Dr. Blissard limits her practice to psy-
chiatry.

Julian Bramlett of Oxford has joined the staff
of Yalobusha County General Hospital at Water
Valley. Dr. Bramlett will maintain his office in
Oxford but will be on call for service at this hos-
pital.

Duane C. Burgess of Hattiesburg gave a talk on
drug abuse to the last meeting of Camp School
PTA in Hattiesburg.

C. Hal Cleveland of Gulfport was elected
president of the Louisiana-Mississippi Ophthal-
mological and Otolaryngological Society at its
32nd annual meeting in Biloxi. Other Mississip-
pians elected to office were Arthur V. Hays of
Gulfport, secretary; Ralph Sneed of Jackson
and Julian E. Boggs, Jr., of Columbus, coun-
selors.

Alton B. Cobb of Jackson appeared on a panel
before the Mississippi Medical and Surgical As-
sociation, Inc., at its 70th Anniversary meeting.
His topic was Medicaid.

Ernest Edward Ellis of Laurel, Oscar Wil-
son Irby and Preston Ray Stodard of Meridi-
an, Thomas J. McDonald of Mantachie, Wes-
ley L. McFarland and Charles Julius Cox
of Bay St. Louis have been re-elected to active
membership in the American Academy of Gen-
eral Practice. Re-election signifies that the physi-
cian has successfully completed 150 hours of
accredited postgraduate medical study in the last
three years.

Thomas Gandy of Natchez exhibited part of his
collection of the pictorial history of old Natchez
at the 1970 Arts Festival in Jackson.

Karl Hatten of Vicksburg has been elected
chairman of the District Two Heart Association.
Dr. Hatten will represent Claiborne, Issaquena,
Sharkey, and Warren counties of the state or-
ganization’s Board of Directors.

C. A. Hollingshead has associated with W. B.
White and T. R. Howell in the Laurel Medi-
cal-Surgical Clinic.

Four physicians have been appointed to one-
year terms on National Academy of General
Practice committees: John B. Howell, Jr. of
Canton, Committee on Insurance; Max L. Pharr
of Jackson, Committee on Mental Health; Wil-
liam E. Lotterhos of Jackson, Executive Com-

mittee of the AAGP; and Hardy B. Wood-
bridge, Jr., of Jackson, Committee on Cancer.

I. C. Knox, Jr. of Vicksburg has been reap-
pointed to the Vicksburg School Board for a
five year term ending in 1975.

Wesley W. Lake of Gulfport was the recipient
of the Mississippi Heart Association’s 1970 Gold
Award at the association’s annual assembly in
Jackson.

James George Logan of Natchez has been cited
in The Encyclopedia of American Biography,
New Series, of the American Historical Com-
pany, Inc., copyright 1970.

William E. Lotterhos and David B. Wilson
of Jackson and W. L. Jaquith of Whitfield at-
tended the 1970 meeting of the President’s
Committee on Employment of the Handicapped
in Washington, D. C.

Robert L. McKinley, Jr., of Tupelo has re-
moved his offices to 805 Garfield for the practice
of neuropsychiatry.

Shelby W. Mitchell of Ellisville was guest
speaker for the annual dinner meeting of the
Lauderdale County Tuberculosis and Respiratory
Disease Association. Dr. Mitchell is acting di-
rector of the Lauderdale County Health Depart-
ment.

Van B. Philpot of Houston delivered a paper
before the Federation of American Societies at
their 54th annual meeting in Atlantic City. Dr.
Philpot recently received his second patent in the
field of snake serum for studies of the protease in-
hibitor in control of hemorrhage.

Walter T. Taylor of Clarksdale has been elect-
ed chairman of the District Four Heart Associa-
tion. Dr. Taylor will coordinate the volunteer ac-
tivities in Coahoma, Quitman, Tallahatchie and
Tunica counties.

Clifford Tillman of Natchez was re-elected to
serve as director of the District One Heart Asso-
ciation and member of the Mississippi Heart As-
sociation Board of Directors at that organiza-
tion’s annual assembly in Jackson.

Virginia S. Tolbert of Ruleville recently ad-
dressed the Ruleville Woman’s Club meeting.
Her subject was leukemia and arthritis.

John R. Young of Natchez has been named the
new chairman of the Executive Committee of the
Adams County Republican Party.

338

JOURNAL MSMA

The following physicians have been elected to
membership by their respective component med-
ical societies in the Mississippi State Medical As-
sociation and the American Medical Association.

Blaylock, Darrell Nolon, Greenville. Born
Purvis, Miss., Sept. 25, 1936; M.D., University of
Mississippi School of Medicine, Jackson, 1962;
interned Baptist Hospital, Nashville, Tenn., one
year; medicine residency, same, July 1, 1963-
June 30, 1964; medicine residency, City of
Memphis Hospitals, Tenn., July 1, 1964-July 31,
1966; elected April 8, 1970 by Delta Medical
Society.

Day, Larry Hale, Hattiesburg. Born Shaw,
Miss., Aug. 31, 1937; M.D., University of Mis-
sissippi School of Medicine, 1952; interned Brooke
General Hospital, San Antonio, Tex., one year;
otolaryngology residency. University Medical
Center, Jackson, Miss., July 1, 1965-June 30,
1969; elected March 12, 1970 by South Mis-
sissippi Medical Society.

Giles, William Gary, Hattiesburg. Born Hat-
tiesburg, Miss., Feb. 11, 1934; M.D., Louisiana
State University School of Medicine, New Or-
leans, 1964; interned Southern Baptist Hospital,
New Orleans, one year; surgery residency, V. A.
Hospital, New Orleans, July 1, 1965-June 30,
1966; orthopaedic surgery residency, Campbell
Clinic, Memphis, Tenn., July 1, 1966-June 30,
1969; elected March 12, 1970 by South Missis-
sippi Medical Society.

Hammett, Larry Joe, Hattiesburg. Born Fort
Worth, Tex., Sept. 18, 1937; M.D., Louisiana
State University School of Medicine, New Or-
leans, 1963; interned Confederate Memorial
Medical Center, Shreveport, La., one year; pe-
diatric residency, same, July 1, 1964-June 30,
1965; otolaryngology residency, same, July 1,
1965-June 30, 1969; elected March 12, 1970 by
South Mississippi Medical Society.

Hartness, Durward Stanley, Kosciusko. Born
Kosciusko, Miss., May 14, 1942; M.D., Univer-
sity of Mississippi School of Medicine, Jackson,
1968; interned. University Medical Center, Jack-
son, Miss., one year; elected Dec., 1969 by
North Central District Medical Society.

Hoover, Jack Clifford, Pascagoula. Born Gyp-

sum, Kan., Jan. 27, 1933; M.D., Tulane Uni-
versity School of Medicine, New Orleans, La.,
1962; interned U. S. Naval Hospital, Pensacola,
Fla., one year; residency, U. S. Naval School of
Aviational Medicine, Pensacola, Fla., Oct., 1963-
April, 1964; obstetrics and gynecology residen-
cy, University Medical Center, Jackson, Miss.,
July 1, 1966-June 30, 1969; elected Dec. 15,
1969 by Singing River Medical Society.

Scott, Edward Gray, Jr., Meridian. Born
Riderwood, Ala., March 23, 1931; M.D., Tulane
University School of Medicine, New Orleans, La.,
1963; interned McLeod Infirmary, Florence,
S. C., one year; general practice residency, E. A.
Conway Charity Hospital, Monroe, La., July 1,
1964-Dec. 31, 1964; medicine residency, V. A.
Hospital, New Orleans, La., Jan. 1, 1965-Dec.
31, 1966; medicine residency, Oschner Founda-
tion Hospital, New Orleans, Jan. 1, 1967-Dec.
31, 1967; cardiology fellowship, same, Jan. 1,
1968-July 1, 1968 and V. A. Hospital, New
Orleans, July 1, 1968-Jan. 1, 1969; elected April
7, 1970 by East Mississippi Medical Society.

Smith, Jimmie Lawson, DeKalb. Born Meridi-
an, Miss., Nov. 29, 1936; M.D., University of
Mississippi School of Medicine, Jackson, 1968;
interned Pensacola Educational Program, Fla.,
one year; elected Dec. 2, 1969 by East Missis-
sippi Medical Society.

Ward, Roderick Dhu, Jr., Raymond. Born Roll-
ing Fork, Miss., Aug. 1, 1930; M.D.. University
of Mississippi School of Medicine, Jackson, 1968;
interned St. Vincents Infirmary, Little Rock, Ark.,
one year; elected March 3, 1970 by Central Medi-
cal Society.

. Cowsert, Louis Earnest, Ocean Springs.

M.D., University of Illinois School of Medi-
cine, Chicago, 1951; interned St. Francis Hospi-
tal, Evanston, 111., one year; surgery residency,
Union Hospital, West Frankfort, 111., July 1, 1952-
June 30, 1957; died May 3, 1970, age 48.

Trudeau, Eugene Alexis, Biloxi. M.D.,
Creighton University School of Medicine,
Omaha, Nebr., 1925; interned Emergency Hos-
pital, Washington, D. C., one year; died May 1,
1970, age 72.

JUNE 1970

339

NATIONAL AND REGIONAL

American Medical Association, Annual Conven-
tion, June 21-25, 1970, Chicago, Clinical Con-
vention, Nov. 29-Dec. 2, 1970, Boston. Ernest
B. Howard, Executive Vice President, 535 N.
Dearborn St., Chicago, 111. 60610.

Southern Medical Association, 64th Annual
Meeting, Nov. 16-19, 1970, Dallas. Mr. Rob-
ert F. Butts, Executive Director, 2601 High-
land Ave., Birmingham, Ala. 35205.

STATE AND LOCAL

Mississippi State Medical Association, 103rd An-
nual Session, May 3-6, 1971, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Howard A. Nelson, 308 Fulton
St., Greenwood, Secretary.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-
taurant, Hernando. Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

340

East Mississippi Medical Society, First Tuesday,
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, April and October. Cherie Friedman,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October, Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell, 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March,
June, September, and December. A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday,
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.
W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m., Old Southern Tea Room, Vicksburg.
Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

JOURNAL MSM A

Book Reviews

Fundamentals of Inhalation Therapy. By Don-
ald F. Egan, M.D. 468 pages with 148 illustra-
tions. St. Louis: The C. V. Mosby Company,
1969. $11.00.

The author of this excellent book states that it
is intended “primarily for the student inhalation
therapist and for the working therapist requiring
a reference for review.” The book consists of 12
chapters dealing with pertinent chemistry, gases,
cardiopulmonary physiology, aerosol and humid-
ity therapy, gas therapy, inhalation therapy, and
the inhalation therapist’s responsibilities to the
chronic care and rehabilitation of patients with
respiratory failure. The final chapter describes
the organization of the inhalation therapy de-
partment and its interrelationship with other med-
ical and hospital functions. Many useful charts are
found in the appendix.

The author presents his material in a lucid
manner and obviously has had considerable ex-
perience both in treating patients with respira-
tory problems and in teaching inhalation thera-
pists. The book is authoritative, well illustrated,
and has an excellent current bibliography with an
adequate index. His use of chemical formulae is
held to the minimum necessary to explain basic
chemical and physiologic principles relating to in-
halation therapy. The chapters on “Aerosol and
Humidity Therapy,” “Gas Therapy,” “Mechan-
ical Ventilation,” and “Inhalation Therapy Man-
agement of Ventilatory Failure,” provide an ex-
cellent in-depth discussion of the respective sub-
jects.

The only major deficiency is the author’s fail-
ure to stress the absolute necessity for “sterile”
nebulizers and ventilators. Although he describes
this equipment in great detail, he virtually ig-
nores the unique ability of nebulizers and respi-
rators to cause severe illness and even death
from bacterial contamination. Such a problem de-
serves strong emphasis on current methods aimed
at preventing or minimizing this serious compli-
cation.

Inhalation therapists will find this publication

to be a valuable and informative reference. In
addition, it will be especially useful to physicians
interested or involved in inhalation therapy and
to those who have the responsibility for develop-
ing an inhalation therapy section. It will be of
special worth to residents or to fellows in pul-
monary disease who will profit not only from
the book but from knowing what the author de-
scribes as “the minimum knowledge for the safe
and effective administration of inhalation thera-
py.”

Guy D. Campbell, M.D.

Handbook of Ocular Therapeutics and Phar-
macology. 3rd Edition. By Philip P. Ellis, M.D.
and Donn L. Smith, M.D., Ph.D. St. Louis: The
C. V. Mosby Co., 1969. $10.75.

This book was written to serve as a quick
reference for the busy practitioner who may have
forgotten a specific dose or side reaction of a
certain drug, as well as a reference to treatment
of specific conditions.

It is divided into two sections. The first sec-
tion, on therapeutics, summarizes the present
medical therapy of most ocular disorders. The
chapter on intraocular infections contains much
valuable information, but is disappointing in one
respect. Perhaps the authors’ poor success in
using intracameral injection comes from using
the buffered preparations presently available or
in using too large doses. This subject needs more
thorough investigation and re-writing.

The second section, on pharmacology, presents
the most commonly used medications that a
practicing ophthalmologist would have occasion
to administer. The action, uses, side reactions,
contraindications, preparations and dosages of
these drugs are presented. A section on pediatric
dosages is included.

The authors present very complete and specific
information in extremely lucid and concise form.
The third edition brings the information up to
date. This book should be in the office of every
physician treating eye diseases.

Joseph B. Rogers, Ph.C., B.S. Phar., M.D.

JUNE 1970

341

for nutritional
support in

G.I.disorders

Berocca

TABLETS

high potency B-complex and C
for nutritional support

AVAILABLE ONLY ON Rx

contains water-soluble vitamins only

b.i.d. dosage provides full
therapeutic amounts

good patient acceptance

no odor, and virtually no aftertaste

Each Berocca Tablet contains:

Thiamine mononitrate 15 mg

Riboflavin 15 mg

Pyridoxine HCI 5 mg

Niacinamide 100 mg

Calcium pantothenate 20 mg

Cyanocobalamin 5 meg

Folic acid 0.5 mg

Ascorbic acid 500 mg

Usual dosage is one tablet b.i.d.

Indications: Nutritional supplementation in conditions in
which water-soluble vitamins are required prophylactically
or therapeutically.

Warning: Not intended for treatment of pernicious anemia
or other primary or secondary anemias. Neurologic involve-
ment may develop or progress, despite temporary remission
of anemia, in patients with pernicious anemia who receive
more than 0.1 mg of folic acid per day and who are in-
adequately treated with vitamin B 12-
Dosage: 1 or 2 tablets daily, as indicated by clinical need.
Available: In bottles of 100.

j-^ROCHEjj

Roche

LABORATORIES

Division of Hoffmann-La Roche Inc.
Nutley, New Jersey 07110

Dr. Brumby Is Inaugurated President,
Dr. Brown Is Named President-Elect

Dr. Arthur E. Brown of Columbus was named
president-elect of the Mississippi State Medical
Association at the 102nd Annual Session, and
Dr. Paul B. Brumby of Lexington was inaugu-
rated 1970-1971 president, succeeding Dr. James
L. Royals of Jackson.

Twelve specialty societies met concurrently
with the Scientific Assembly before which a
total of 38 essayists appeared. Sixty scientific and
technical exhibits were presented to meeting reg-
istrants.

Scene of the meeting was the Buena Vista hotel
and motel at Biloxi. Registration totaled 996 with
543 members, 115 physician-guests, 210 mem-

Three years of the association’s presidency are
represented by, from left, Drs. James L. Royals,
1969-70; Paul B. Brumby, 1970-71; and the new
president-elect, Arthur E. Brown, 1971-72.

bers of the Woman’s Auxiliary, 114 exhibitors
and other guests, and 14 staff.

A busy House of Delegates acted on 21 re-
ports and 13 resolutions with a 14th lying on the
table until 1971 in two meetings. Meanwhile,
reference committees heard debate, comment,
and suggestions leading to policy decisions.

The president and chairman of the Board of
Trustees welcome the new secretary-treasurer, Dr.
Raymond S. Martin, Jr., of Jackson, center, who is
congratulated by President Brumby and Board Chair-
man Mai. S. Riddell , Jr.

In his address to the opening meeting of the
House of Delegates, Dr. Royals discussed the
care delivery system which he characterized as
being on trial. He said that “agencies of govern-
ment engaged in care financing are attacking the
system, a variety of proposals for radical change
are heard in the halls of Congress (and) insur-
ance and Blue plans are introducing subtle in-
fluences upon it.”

He called for adjustment to change by physi-
cians but urged them to assume greater roles of
leadership by “an inquisitive outreach in a con-
stant search to improve and a willingness to ex-
periment with promising change” in what he
called hallmarks of medical progress.

The president hit hard on medical manpower
shortages, pointing out that Mississippi has only
half the physicians-to-population ratio as the
national average. He called for carrying care to
the poor and said that “while the majority of
Mississippians receive excellent care, many do
not.”

“We must in all candor and honesty recognize
that there are large groups in our state who re-

JUNE 1970

343

ANNUAL SESSION / Continued

ceive little or no medical care,” he asserted. He
said that “it is not sufficient for us to proclaim
that we never turn a patient away or to say
that we will care for anyone who comes to us.”
He called for taking care to the economically,
intellectually, educationally, and emotionally de-
prived.

Dr. Royals said that in the midst of all of this,
we must also look within, seeking effective means
for self-regulation and the making of worthy and
responsible judgments which will be accepted by
third parties and other sponsors of care financing.
He called for a statewide system of peer review.

The president commended the Board of
Trustees in organizing a Committee on Peer Re-
view, and he asked the House to make it per-
manent with adequate staff and financing. He
said that counterpart committees must be or-
ganized at local level. Failing to do this, he
said, “we shall certainly be judged by others.”
Calling on physicians to participate fully with

time, effort, and means, he said that “the most |
tragic hour in American medicine comes when a
physician withdraws himself in spirit and sub-
stance from medical organization.

“He renders himself impotent, and he chips
a stone from our foundation,” he added. “The
whole is never greater than the sum of its parts,
and no man is an island. His dissent should not
be translated into destruction of his organization,
of his colleagues, or of himself. He simply does
not have that right.”

The delegates gave Dr. Royals a standing ova-
tion and applauded the unanimous action of the
House approving the address.

Also appearing before the House of Delegates
as principal guest speaker was Dr. Gerald D.
Dorman of New York, president of the American
Medical Association.

Through the Committee on AMA-ERF, a
check for $ 1 f , 1 00 from the association and Aux-
iliary was presented to the University of Missis-
sippi School of Medicine.

New vice presidents are Drs. John R. Lovelace

Dr. J. T. Davis of Corinth, vice chairman of the occlusion. Scientific exhibit was biggest in years with

Board of Trustees, studies scientific exhibit by UMC 21 presentations.

Department of Surgery on management of coronary

344

JOURNAL MSMA

The Reference Committee on Medical Practices listens intently
to member discussing a resolution. From left. Drs. W. B. Howard,
Joseph E. Johnston, Louis A. Farber, Chairman Joseph B. Rog-
ers, and Clyde A. Watkins. Assistant executive secretary Cody
Harrell listens in foreground. Left, Immediate Past President
Rogers, President Royals, and senior living past president. Dr.
Gus Street of Vicksburg, reflect on association progress. Right,
Dr. Brumby is inaugurated 1970-71 president as Executive Sec-
retary Rowland B. Kennedy holds association’s historic Bible
and Board Chairman Riddell administers oath of office.

JUNE 1970

345

Past presidents of the association enjoy
fraternal and traditional breakfast with
special guests, Drs. Royals and Brum-
by, candidates for select circle. Left, Dr.
Gerald D. Dorman of New York, pres-
ident of the American Medical Asso-
ciation, appeared as principal guest
speaker of the annual session. He ad-
dressed the House of Delegates at
opening meeting.

346

JOURNAL MSMA

i

A Fifty Year Club “freshman,” Dr. J. A. K. Birch-
ett of Vicksburg, replete with beanie, receives coveted
certificate and gold lapel pin from Board Chairman
Riddell. The club is sponsored by the Board of Trust-
ees to honor physicians who have practiced 50
years in Mississippi.

of Batesville, J. Dan Mitchell of Jackson, and
Eldon L. Bolton of Biloxi.

Re-elected as associate editor of the Journal
was Dr. George H. Martin of Vicksburg.

Dr. C. D. Taylor, Jr., of Pass Christian was
named delegate to AM A. Elected alternate dele-
gate to AMA was Dr. Stanley A. Hill of Corinth.

Dr. Lyne S. Gamble of Greenville was elected
Trustee from District 1. Re-elected to Trustee
posts were Drs. James O. Gilmore of Oxford,
District 2, and J. T. Davis of Corinth, District 3.

Dr. Raymond S. Martin, Jr., of Jackson was
elected Secretary-Treasurer. Named to councils
were Dr. Daniel L. Hollis of Biloxi, Council on
Budget and Finance; Dr. Arthur E. Brown of
Columbus, Council on Constitution and By-Laws;
and Dr. Charles N. Floyd of Gulfport, Council
on Medical Education.

Elected to the Judicial Council were Drs. Wil-
liam E. Weems of Laurel, District 7; Wendall B.
Holmes of McComb, District 8; and Dr. James
T. Thompson of Moss Point, District 9. Dr.
Thompson will serve as chairman.

New members of the Council on Legislation
are Drs. Arthur A. Derrick of Durant, District 4;
John G. Caden of Jackson, District 5; and Frank
H. Tucker, Jr., of Meridian, District 6.

The Council on Medical Service has three new
members: Dr. C. R. Jenkins of Laurel, District
7; Dr. Jack A. Atkinson of Brookhaven, District
8; and Dr. Bedford Floyd of Gulfport, District 9.

Dr. William E. Lotterhos of Jackson was re-
elected Speaker of the House, and Dr. John B.

Dr. James P. Spell of Jackson, right, receives Aes-
culapius Award and cash honorarium from Scientific
Assembly Chairman Walter H. Simmons for best
scientific exhibit by a member of the association.
Subject of Dr. Spell’s presentation was “Systemic
Clues to Occult Cancer.”

Howell, Jr., of Canton was named to another
term as Vice Speaker.

Delegates Act on Big
Agenda at 102nd

A heavy agenda of 21 reports and 14 resolu-
tions made for a busy House of Delegates at the
102nd Annual Session during the May 11-14
Biloxi meet. Emerging from a year of intensive
activity, the Board of Trustees submitted seven
reports to the House.

Principal business items before the delegates
included peer review, care delivery, the Hinder
Report pending before AMA, intensified legisla-
tive program, membership for medical students,
the state abortion law, limited licensure for
foreign trained physicians, and association fi-
nances.

Acting on a recommendation of the Board of
Trustees, the House accorded constitutional status
to the new Committee on Peer Review and made
it a parent body to counterparts at component
medical society level. The committee succeeds
the state Grievance Committee in its former func-
tions and also will examine the quality of care
and offer its services in making responsible
judgments for third party financing mechanisms.

A number of related policy actions reaffirmed
the association's support of the private care de-
livery system, including assumption of a leader-

5

£

JUNE 1970

347

ANNUAL SESSION / Continued

ship role in working with agencies of government,
third parties, and organizations sponsoring care
plans.

The delegates agreed that the massive and
complex Himler Report, referred to each state
association by AMA, could not be disposed of
at the annual session. In a three-part action, the
House approved those portions of the report
which included previously-established policy,
agreed that information gathering as recom-
mended in various sections be undertaken, and
asked for a task force to study and disseminate
information on the remainder, much of which is
controversial.

The House also asked that the Himler task
force report to the 103rd Annual Session in 1971
with a view toward concluding work on the docu-
ment with “a final policy disposition.”

Adopting another Board recommendation, the
delegates called for a positive legislative program
with a personal commitment from every member
of the association. Additional staff was authorized
for day-to-day liaison, and continual physician-
to-legislator contact was urged. The Emergency
Medical Care Unit at the Capitol will be con-
tinued, operating during sessions of the legis-
lature.

The House approved a resolution authorizing
the Board of Trustees to establish a degree of
membership for junior and senior medical stu-
dents and to create on a provisional basis a new
component medical society for this purpose at
the University Medical Center.

A new policy on the state’s abortion law
would forbid the procedure except when the
pregnancy results from forcible or statutory rape
or incest, when continuation of the pregnancy
poses a threat to the health or life of the mother,
or when, in cognizant medical opinion, there
is a probability the infant will be born deformed.

The procedure, the policy statement continues,
should be undertaken by a physician only when
consultation has been obtained in writing from
another physician and is performed in a licensed
hospital.

Another key action was approval of limited
licensure for carefully selected foreign trained
physicians for practice limited to state institutions.
Licentiates would have to be approved by the
superintendent of the institution and his gov-
erning board, the local medical society, the dis-
trict association Trustee, and the medical mem-
ber of the State Board of Health for the area.

Acting favorably on two items, a major report
from the Board of Trustees and a resolution from
the Delta Medical Society, the House approved a

Members of the Fifty Year Club at annual ses- table , and Cindy Sanders, association membership di-

sion participated in special luncheon meeting. Club rector who serves as club secretary.

“ officers " are Board Chairman Riddell, at head of

348

JOURNAL MSMA

A/0/XVI^C

Dr. W. J. Aycock of Calhoun City was winner of 1970 MSMA-Rob-
ins Award for outstanding community service by a physician. Pres-
ident Royals applauds honoree as family joins in congratulations.
Right, House Speaker William E. Lotterhos follows floor dis-
cussion as he presides. Right, Dr. Brown accepts office of president-
elect in remarks to House of Delegates.

3 49

JUNE 1970

'ft

Summer time. ..monilia time!

No wonder you see so many more cases of vaginal
moniliasis during this season. A damp, warm
bathing suit provides a perfect breeding ground for
fungal invaders. But your patients need not suffer
the pain, the embarrassment and the discomfort
of these stubborn infections. Nor the disappointment
which comes when they find “the cure didn’t take.”

Candeptin avoids disappointment.

With Candeptin, you and your patients have g
reason for confidence. A single , 1 4-day course
of therapy with Candeptin is usually sufficie:
to eradicate the invader, while rapidly relievin:
itching, burning, discharge and malodor.

And Candeptin is “cidal” as well as “static”;

1 00 times more potent than nystatin in vitro,
it has achieved culture-confirmed cure rates of
90% and more (even in notoriously difficult
pregnant patients) . Why not maximize your
chances of success by adopting effective, well-
tolerated Candeptin as your agent of first choice?

Agent of first choice

Candeptin

candicidin

VAGINAL TABLETS/OINTMENT

Candeptin ®candicon

Formula:

Candeptin Vaginal Ointment
contains a dispersion of
candicidin powder equivalent
to 0.6 mg. per gm. or 0.06%
candicidin activity in U.S.P.
petrolatum. 3 mg. of candicidin
is contained in 5 gm. of ointment
or one applicatorful. Candeptin
Vaginal Tablets contain
candicidin powder equivalent to
3 mg. (0.3%) candicidin activity
dispersed in starch, lactose and
magnesium stearate.

Indications:

Vaginal moniliasis due to Candida
albicans and other Candida species.

Contraindications:

Patient sensitivity to any of the
components. During pregnancy
manual tablet insertion may be
preferred since the use of the
ointment applicator or tablet
inserter may be contraindicated.

Caution:

Clinical reports of sensitization
or temporary irritation with
Candeptin Vaginal Ointment or
Vaginal Tablets have been
extremely rare. To avoid re-
infection, it is recommended that
the patient refrain from sexual
intercourse during treatment
or the husband wear a condom.

Dosage:

One vaginal applicatorful of
Candeptin Ointment or one
Vaginal Tablet is inserted high
in the vagina, twice a day,
in the morning and at bedtime,
for 14 days. Treatment may be
repeated if symptoms persist
or reappear.

Dosage forms:

Candeptin Vaginal Ointment
is supplied in 75 gm. tubes with
applicator (14-day regimen
requires 2 tubes). Candeptin
Vaginal Tablets are packaged
in boxes of 28, in foil, with
inserter— enough for a full
course of treatment. Store under
refrigeration.

Federal law prohibits dispensing
without prescription. CANDEPTIN
is a registered trade-mark of
Julius Schmid, Inc.

JULIUS SCHMID
PHARMACEUTICALS
New York, N.Y. 10019

dues increase to $100 for state association dues
effective in 1971. The increase is earmarked for
peer review, legislative work, the building amor-
tization, and inflationary increases in routine
operations.

The House also approved a new system of
dues billing by the executive office to relieve vol-
unteer physician-secretaries of component socie-
ties of the task. The billing will include dues for
the local society, state medical association, AMA,
and voluntary dues for MPAC and AMPAC.

In other actions, the House of Delegates:

— Commended the secretary-treasurer, Dr.
Walter H. Simmons of Jackson, for his service.

— Upheld an opinion of the Judicial Council
that physicians should not maintain offices for
private practice for care of outpatients in com-
munity, county, nonprofit, or church-affiliated
hospitals, except for pathologists and radiologists
or those in medical education, especially in the
family practice training program. Exceptions
were made in cases of private proprietary hospi-
tals or to physician-owners when the medical staff
approves the practice.

— Directed accolades to Speaker William E.
Lotterhos of Jackson and Vice Speaker John B.
Howell, Jr., of Canton for “fair, impartial, and
efficient conduct of our business in the House of
Delegates.”

— Approved and commended the report and
representation of AMA Delegates Howard A.
Nelson of Greenwood and G. Swink Hicks of
Natchez.

— Rescheduled annual sessions for 1971, 1972,
and 1973 to avoid conflict with Mother’s Day
and municipal elections.

— Set the dates of the 106th Annual Session
for May 6-9, 1974, at the Gulf Coast.

— Applauded the new building addition and
asked members to visit their new facility at
Jackson.

— Expressed satisfaction over the Professional
Corporation Act sponsored successfully by the
association but cautioned members who contem-
plate incorporation to consult tax advisers and
legal counsel.

— Thanked the Council on Scientific Assembly
for the outstanding scientific program and ex-
hibits.

— Urged continued participation by all phy-
sicians in voluntary support of medical education
through AMA-ERF.

— Fixed as policy that any practitioner who
holds himself out as capable of diagnosing and
treating human disease meet the same statutory

35 1

New officers for Mississippi Association of Pathologists are, from
left, Drs. Roland F. Samson, secretary; George M. Sturgis, past
president; Carl G. Evers, president; and William V. Hare, past
secretary. Left, Dr. M. Beckett Howorth, Jr., reports to House
as chairman of Reference Committee on Reports of Officers and
Board of Trustees. Right, Vice Speaker John B. Howell, Jr., has
able assistance of 1969-70 Auxiliary President Faye Lehmann in
prize drawing.

3 52

JOURNAL MSMA

The Woman's Auxiliary elected a new
slate of officers for 1970-71. Seated
left to right, the ladies are Mesdames
Curtis Caine, Jackson, president; T. E.
Ross, III, Hattiesburg, president-elect;
and Clarence H. Webb, Jr., Jackson,
first vice-president. Standing are Mes-
dames William H. Preston, Jr., Boone-
ville, second vice-president; H. H. Mc-
Clanahan, Jr., Columbus, fourth vice-
president; David Wilson, Jackson,
treasurer; and Joe Herrington, Natchez,
recording secretary. Right center. Dr.
Brumby discusses new products with
Charles Kirkland, Stuart Co. profes-
sional service representative. Lower
right. President Royals exchanges greet-
ings with Ben Evans. Jr., of William P.
Poythress Co.

JUNE 1970

353

; ; >

real broad spectrum,
'r including A

susceptible strains of
Pneumococcus*
“Staph”* “Strep”* f "
H. influenzae* V
M. pneumoniae (PPLO)*

N. gonorrhoeae*

low incidence
k of diarrhea

f outstanding record
of clinical success

therapeutic blood levels
usually persisting \A
around-the-clock#

Mississippi Ob-Gyn Society officers are, from left, Drs. George
Ball, secretary-treasurer; William R. Raulston, president; Wil-
liam S. Cook, section chairman; and Warren C. Plauche, section
secretary. Lower left. Drs. M. Beckett Howorth, Jr., and Benton M.
Hilbun are chairman and secretary, respectively, of Section on
Surgery. Lower right, Mrs. G. Prentiss Lee of Portland, Ore.,
AMA Auxiliary First Vice President, was featured speaker for
ladies’ meet. On left is Mrs. Curtis W. Caine, 1970-71 president,
and right is Mrs. Louis C. Lehmann. 1969-70 president.

4:

-£)»

•2!

Q

L'i

'•*0

JUNE 1970

357

ANNUAL SESSION / Continued

standards for licensure as doctors of medicine.

— Asked that tax incentives be given to phy-
sicians who practice in rural areas in the United
States by necessary amendment of the Internal
Revenue Code of 1954.

— Recognized the shortage of physicians and
called on “the State of Mississippi to do those
things necessary in support of the University of
Mississippi School of Medicine to increase the
size of classes of medical students to the end that
the state may enjoy the benefits of larger gradu-
ating classes.”

— Recommended location of a new training
facility for the mentally retarded in or near Ox-
ford, Mississippi.

— Protested the burdensome regulations and
paperwork in Medicaid and asked the commission
to clarify and simplify forms by the end of 1970,
offering the services of the association in the task.

— Called for continuation of the emergency
medical helicopter transportation demonstration
project with bases and aircraft at Greenwood,
Jackson, and Hattiesburg.

— Provided exemption from state association
dues for members who are 70 years of age prior
to the year of exemption and who have been
active members for 10 consecutive years.

— Expanded the membership of the Council on
Budget and Finance to five from the present three
members effective in 1971 with all members to
be elected by the House of Delegates.

The delegates were in session Monday, May
11, with reference committee meetings that after-
noon. Final actions, including election of 1970-
71 officers, Trustees, and council members, came
on May 14, the concluding day.

Scientific Assembly
Begins Work for ’71

The 1971 Annual Session is set for May 3-6,
with headquarters at the Buena Vista hotel and
motel at Biloxi. The Scientific Assembly has al-
ready begun planning for the 103rd.

Acting by separate sections during the recent
102nd Annual Session, the seven components of
the Scientific Assembly named new chairmen,
and three sections elected new secretaries.

Under the By-Laws, a section chairman serves
a term of only one year, but section secretaries
are elected for three years. Each office carries an

358

5ynthrnid

(sodium levothyroxine)

it

Indications: SYNTHROID (sodium levothyroxine) is specific 1
ment therapy for diminished or absent thyroid function r
from primary or secondary atrophy of the gland, congenital1
surgery, excessive radiation, or antithyroid drugs. Indica
SYNTHROID (sodium levothyroxine) Tablets include my
hypothyroidism without myxedema, hypothyroidism in pre
pediatric and geriatric hypothyroidism, hypopituitary hype
ism, simple (non-toxic) goiter, and reproductive disorders as
with hypothyroidism. SYNTHROID (sodium levothyroxine) I
is indicated in myxedematous coma and other thyroid dysfi
where rapid replacement of the hormone is required. Wh<
tient does not respond to oral therapy, SYNTHROID (sodii
thyroxine) injection may be administered intravenously to a
question of poor absorption by either the oral or the intran
route.

Precautions: As with other thyroid preparations, an ove
may cause diarrhea or cramps, nervousness, tremors, tach
vomiting and continued weight loss. These effects may bet
four or five days or may not become apparent for one to thre<
Patients receiving the drug should be observed closely for
thyrotoxicosis. If indications of overdosage appear, disc
medication for 2-6 days, then resume at a lower dosage
patients with diabetes mellitus, careful observations should I
for changes in insulin or other antidiabetic drug dosage
ments. If hypothyroidism is accompanied by adrenal insuffici
Addison’s Disease (chronic subcortical insufficiency), Simi
Disease (panhypopituitarism) or Cushing's syndrome (hype
alism), these dysfunctions must be corrected prior to anc
SYNTHROID (sodium levothyroxine) administration. Tl
should be administered with caution to patients with cardio'
disease; development of chest pains or other aggravations
diovascular disease requires a reduction in dosage.

Contraindications: Thyrotoxicosis, acute myocardial infarc-

Side effects: The effects of SYNTHROID (sodium levoth
therapy are slow in being manifested. Side effects, when
occur, are secondary to increased rates of body metabolism!
ing, heart palpitations with or without pain, leg cramps, ancj
loss. Diarrhea, vomiting, and nervousness have also been of
Myxedematous patients with heart disease have died from;
increases in dosage of thyroid drugs. Careful observation
patient during the beginning of any thyroid therapy will £
physician to any untoward effects.

In most cases with side effects, a reduction in dosage folk
a more gradual adjustment upward will result in a more e
indication of the patient’s dosage requirements without the
ance of side effects.

Dosage and Administration: The activity of a 0.1 mg. SYN’
(sodium levothyroxine) TABLET is equivalent to approximal
grain thyroid, U.S.P. Administer SYNTHROID tablets as |
daily dose, preferably after breakfast. In hypothyroidism J
myxedema, the usual initial adult dose is 0.1 mg. daily, and>i
increased by 0.1 mg, every 30 days until proper metabolic ba j
attained. Clinical evaluation should be made monthly £*l
measurements about every 90 days. Final maintenance dos,;
usually range from 0.2-0. 4 mg. daily. In adult myxedema, 1
dose should be 0.025 mg. daily. The dose may be increase^
mg. after two weeks and to 0.1 mg. at the end of a second two
The daily dose may be further increased at two-month inte
0.1 mg. until the optimum maintenance dose is reached (0.1 jj
daily).

Supplied: Tablets: 0.025 mg., 0.05 mg., 0.1 mg., 0.15 mg., 0.2
mg., 0.5 mg., scored and color-coded, in bottles of 100 and 5C
tion: 500 meg. lyophilized active ingredient and 10 mg. of IV
N.F., in 10 ml. single-dose vial, with 5 ml. vial of Sodium L
Injection, U.S.P., as a diluent.

SYNTHROID (sodium levothyroxine) INJECTION may be £
tered intravenously utilizing 200-400 meg. of a solution coi
100 meg. per ml. If significant improvement is not shown th<
ing day, a repeat injection of 100-200 meg. may be given.

FLINT LABORATORIES

DIVISION OF TRAVENOL LABORATORIES. INC

Morton Grove. Illinois 60053

xpnsesa

n the Embankment. Two figures emerge into silhouette against a
1 street lamp. The flare of a match reveals the profile of Sherlock
es. As he lights his calabash, his companion speaks:

ove, Holmes, that amazing intuition of yours has proved right
. What we’re looking for is a single entity. I thought we were
lg with several others— even twins. But now— I'd say we’ve
/ered a double agent.”

me more, Watson, and be quick about it!”

>on withdraws a folded paper from inside his greatcoat, and
aloud from it):

“Is that why there’s such a smooth, predictable response, W'atson?”

“Quite! With agent T4, SYNTHROID, the chances of a precipitous
rise in metabolic rate are lessened.”

“But how does ‘free’ thyroxine fit into the picture?”

“Well, Holmes, you might call it the tissue thyroid hormone— because
‘free’ thyroxine (that is, thyroxine not bound to protein) is active at
the tissue level. It is gradually released from thyroxine-binding pro-
teins. Each daily dose of SYNTHROID is mostly bound to thyroid-
binding proteins, and slowly released as 'free' thyroxine— the form in
which it is metabolically active.”

key to the whole cypher is SYNTHROID (sodium levothy-
e)”. . .

h! Watson, not so loud! You’ll alert our quarry.”

;on continues): “A single entity that serves two functions.”

taster stroke, Watson.”

ow along, Holmes. In the neighborhood of 95% of the circulat-
lyroid hormone is levothyroxine— T4 as you call it. T4 is bound
/roxine-binding proteins in the serum. It becomes available only
rnlly to tissue cells— as free thyroxine.”

“Magnificent, Watson! So protein-bound thyroxine is the major form
of circulating thyroid hormone, and it is released as ‘free’ thyroxine.
And that’s why SYNTHROID is able to simulate the normal process
so artfully. Q.E.D.”

“Not so fast. Holmes. SYNTHROID works for the physician, too.
Because its dosage is more precisely controllable, and because re-
sponse is so smooth and predictable, the doctor gets fewer phone calls
in the wee hours from agitated patients. Both parties get more sleep!”

“Comforting, my dear doctor, to know that SYNTHROID, the
‘single agent,’ cleverly does the job of two.”

Synthroid (sodium levothyroxine)

ORGANIZATION / Continued

automatic seat and vote in the House of Delegates
to assure proper representation of each scientific
section.

Secretaries of the seven sections are on stag-
gered terms so that annual elections are for two,
two, and three in any three-year period.

Named to head the Section on EENT is
Dr. Richard L. Blount of Jackson; while Dr.
James K. Williams, Jr., of Pascagoula continues
to serve as section secretary.

Heading the Section on General Practice is
Dr. James O. Stephens of Magee. Dr. W. John-
son Witt of Jackson remains at his post as
secretary.

The internists chose Dr. C. Ralph Daniel, Jr.,
of Jackson as chairman of the Section on Medi-
cine. Dr. S. H. McDonnieal, Jr., of Jackson, en-
ters his first year as section secretary.

Dr. William S. Cook of Jackson heads the Sec-
tion on Obstetrics and Gynecology. Serving his
second year as secretary is Dr. Warren Plauche
of Biloxi.

Dr. John D. McEachin of Meridian is the new
chairman of the Section on Pediatrics. New sec-
tion secretary is Dr. John R. Jackson of Hatties-
burg.

Dr. Hugh B. Cottrell of Jackson will chair the
Section on Preventive Medicine. Dr. Frank M.
Wiygul, Jr., of Jackson will continue as section
secretary.

Advancing from secretary to chairman, Dr.
M. Beckett Howorth, Jr., of Oxford heads the
Section on Surgery. Named to the post of secre-
tary for a three-year term is Dr. Benton M. Hil-
bun of Tupelo.

Dr. Raymond S. Martin, Jr., of Jackson, asso-
ciation secretary-treasurer, is constitutional chair-
man of the Council on Scientific Assembly.

Dr. Martin said, “The council will be meeting
this summer to review preliminary plans for the
103rd Annual Session and to begin actively work-
ing on the program.”

He said that the exhibit prospectus for techni-
cal exhibitors will be released this fall. Specialty
societies are invited to submit plans for concur-
rent meetings and requests for assignment of
rooms, including those for meal occasions, he
added.

The president, Dr. Paul B. Brumby of Lexing-
ton, and the president-elect. Dr. Arthur E. Brown
of Columbus, are ex officio members of the Coun-
cil on Scientific Assembly under the By-Laws.

Gettysburg Commission
Is Headed by M.D.

A Mississippi physician heads the commission
which is directing a project to place a memorial
in the Gettysburg National Park honoring state
Confederate dead. Dr. M. Ney Williams, Jackson,
anesthesiologist, chairs the eight-member group
appointed by the Governor.

Members of the Gettysburg Commission appoint-

ed by Gov. John Bell Williams recently conferred
with noted sculptor Donald DeLue of Leonardo.
N. Y ., far left, who has been commissioned to
execute the Mississippi Memorial. Committee mem-
bers are, from second left, Ed Sturdivant of Jackson,
Dr. M. Ney Williams of Jackson, and Associate Su-
preme Court Justice Tom P. Brady of Brookhaven.

Dr. Williams said that the noted sculptor.
Donald DeLue of Leonardo, N. Y., has been
commissioned to execute the Mississippi memori-
al in bronze. It will stand on a frequently visited
site of the Pennsylvania battlefield near the road
leading to the Dwight Eisenhower farm.

Visiting Jackson recently to meet with the com-
mission, Mr. DeLue displayed a working model
of the memorial. It is a statue of two soldiers on
the battlefield “devoted to country, honor, and
integrity of the men who fought and died at
Gettysburg.”

Mr. DeLue said that “it is not to be militaristic
but to pay honor and tribute to the men them-
selves.”

The finished memorial, destined to stand ad-
jacent to the Louisiana monument, will be of
heroic proportion, standing 17 feet in height.
Two years will be required to complete the work,
Mr. DeLue said.

Funds for the memorial were appropriated by
the 1970 Regular Session of the Legislature, Dr.

3 60

JOURNAL MSM A

, Williams said. Mr. DeLue has executed a number
of important memorials, including the Louisiana
monument and one to the Confederate army and
navy at Gettysburg. He has among his credits
the statue of a Green Beret at Ft. Bragg, N. C.

Dr. Williams’ colleagues on the memorial com-
mission are Supreme Court Justice Tom P. Brady
of Brookhaven, Ed Sturdivant of Jackson, Tom
W. Crigler of Macon, Gary Evans of Greenwood,
Clarence Pierce of Vaiden, noted Civil War his-
torian Albert Andrews of Jackson, and Rep. Stone
Barefield of Hattiesburg.

Governor Names Three
to Board of Health

Gov. John Bell Williams has named two physi-
cians as new members of the Mississippi State
Board of Health and reappointed a member for
another six year term. The appointments are sub-
ject to confirmation by the state senate.

Dr. G. Lacey Biles of Sumner was appointed
to succeed Dr. Julian C. Bramlett of Oxford,
representing Public Health District 2.

Dr. S. Lamar Bailey of Kosciusko is the new
member from Public Health District 4, succeed-
ing Dr. Joseph Guyton, formerly of Pontotoc,
who has relocated in Memphis for the practice
of psychiatry.

Named to succeed himself for a six-year term
is Dr. Lamar Arrington of Meridian, a 12-year
veteran member.

Nominees for Board of Health posts are
named by the state medical association under
Mississippi law. The governor made selections
from among three nominees for each post. These
were named by the House of Delegates at the
1969 annual session. All three terms run from
Jan. 1, 1970, through Dec. 31, 1975.

Nominees for the District 2 post were Dr.
Biles, Dr. Bramlett, and Dr. John R. Lovelace of
Batesville. District 4 nominees were Dr. Bailey,
Dr. Thomas N. Braddock, Jr., of West Point, and
Dr. Lester D. Webb of Calhoun City.

Considered for the District 5 were Drs. Arring-
ton, John R. Laird of Union, and Omar Simmons
of Newton.

Other medical members of the State Board of
Health are Drs. Dewitt Hamrick of Corinth, John
G. Egger of Drew, Joseph G. McKinnon of Hat-
tiesburg, G. Swink Hicks of Natchez, and H. C.
Ricks, Sr., of Jackson.

Dr. Felix K. West of Clarksdale is the dental

member. Dr. Hugh B. Cottrell of Jackson is state
health officer and member-at-large selected by
the Board. Dr. Frank J. Morgan, Jr., of Jackson
is assistant state health officer. There is also an
optometric member of the Board.

At the recent 102nd Annual Session, no nom-
inees for the Board of Health were named, since
no terms expire in 1970.

Board of Trustees
Elect New Officers

The nine-member governing body of the asso-
ciation, the Board of Trustees, has renamed Dr.
Mai S. Riddell, Jr., of Winona, District 4 Trustee,
as its 1970-71 chairman. Dr. J. T. Davis of Cor-
inth, District 3, was re-elected vice chairman.

Dr. William O. Barnett of Jackson, District 5,
is the Board’s secretary. He, the chairman, and
vice chairman make up the executive committee.

Dr. Lyne S. Gamble of Greenville was elected
Trustee from District 1. Re-elected to Trustee
posts were Drs. James O. Gilmore of Oxford.
District 2, and J. T. Davis of Corinth, District 3.

Continuing to serve current terms are Drs.
James T. Thompson of Moss Point, District 9.
Guy T. Vise of Meridian. District 6, W. E. Moak
of Richton, District 7, and Everett Crawford of
Tylertown, District 8.

Seven general officers meet with the Board
regularly but without the right to vote. They are
the president, president-elect, secretary-treasurer,
speaker, vice speaker, and AMA delegates.

Florida Presents
OB-GYN Seminar

The University of Florida college of Medicine
at Gainesville will present a Seminar in Obstet-
rics and Gynecology Nov. 19-20, 1970.

Guest speakers will be Dr. Lawrence L. Hes-
ter, professor and chairman, department of ob-
stetrics and gynecology. Medical College of South
Carolina; and Dr. William Normal Thornton.
Jr., professor and chairman, department of ob-
stetrics and gynecology, University of Virginia
School of Medicine.

For further information, contact: Division of
Postgraduate Education, J. Hillis Miller Health
Center, Box 758. College of Medicine, Gaines-
ville, Fla. 32601.

36 1

JUNE 1970

ORGANIZATION / Continued

Dr. Barnett Named
Physician of the Year

Dr. William O. Barnett, professor of surgery,
University of Mississippi Medical Center, was se-
lected to receive the Mississippi Association of
Medical Assistant’s award of “Physician of the
Year." The announcement was made at the or-
ganization’s annual
state convention on
the Gulf Coast.

In making the an-
nouncement, Mrs.
Mary Adeline Pace,
President, stated,
“Education is the pri-
mary purpose of our
organization on local,
state, and national

levels, and it is the

feeling of our mem-
bership that MAMA’s

Dr. Barnett educational programs

throughout the state
have been greatly enhanced through Dr. Bar-

nett’s interest, advice and encouragement during
1969-70." Dr. Barnett was presented an engraved
plaque.

A native Mississippian, Dr. Barnett has been
active in medical education since joining the fac-
ulty of the University of Mississippi School of
Medicine in 1955.

At the present time he serves the Mississippi
State Medical Association as chairman of the
Council on Medical Education, Trustee from Dis-
trict Five, and secretary of the Board of Trustees,
is president of Central Medical Society and an
associate councilor of Southern Medical Associa-
tion.

Hinds County Children
Immunized Against

Rubella

Thousands of Hinds county youngsters made
a “Children’s Crusade” to health clinics Sunday,
May 31, for immunity against Rubella, or Ger-
man measles.

Dr. H. B. Cottrell, executive officer, State
Board of Health, said the “Stop Rubella Sunday”
was another in a series of county-wide immuniza-
tion programs by the state agency.

3 62

Dr. Durward L. Blakey, director of the Di-
vision of Preventable Disease Control, State
Board of Health, said over 80,000 doses of Ru-
bella vaccine have been given since the agency
began the program in October of 1969.

He said at least 30,000 children got shots in
Hinds county on May 31 with the number pos-
sibly going as high as 50,000, making it one of
the largest single-day programs in the Southeast.

Paul Turner, of the Vaccination Assistance
Program, State Board of Health, and supervisor
of the statewide immunization program, said pro-
grams already have been carried out in 44 coun-
ties, and another 15 counties will be reached
“within the next six weeks.”

Dr. Eric McVey, director of the Hinds County
Health Department, said 25 clinics were set up
for “Stop Rubella Sunday” on May 31.

“The clinics were located in places most easily
accessible to the people,” said Dr. McVey. “The
county health department building was open that
day as a clinic and as the communications head-
quarters.”

He added: “This is a community project

backed by medical organizations, and it is one of
the most important things we can do in a pro-
gram of modern preventive medicine. We had
about 18 sites inside Jackson and about seven
more outside Jackson.”

Dr. McVey said the Rubella vaccine was of-
fered to all children from the age of one year
through the age of eleven.

The State Board of Health paid one-third of
the cost of the vaccine, and Hinds county and
the City of Jackson agreed to share another third
of the cost. The other third came from civic and
service organizations in the county.

Turner said some of the cost was defrayed
through contributions made by individuals. He
said cost of the vaccine averages about a dollar
per dose. He said “it appears at this time that a
dose would give lifetime immunity.”

The program in Hinds county is part of a
statewide effort by the State Board of Health to
immunize children from one through eleven,
with first priority on those five through seven. Tur-
ner said that the program in Hinds county reached
the wider age span (one through eleven) because
of the financial support pledged by the city and
county governments.

Each clinic was manned by a physician, two
technicians, two nurses, six clerks and a site co-
ordinator. Policemen and county deputies were
on duty at each clinic to direct traffic and to
keep the lines orderly.

JOURNAL MSM A

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Index to Advertisers

Arch Laboratories 363

Breon Laboratories 8

Bristol Laboratories 16, 17

Burroughs- Wellcome 352B

Campbell Soup Company 328A

Dow Chemical Company 340A

Flint Laboratories 358, 359

Highland Hospital 10

Hill Crest Hospital 14

Hoechst Pharmaceuticals 12

Hvnson, Westcott and Dunning, Inc. 3

Kay Surgical 363

Lederle Laboratories 4, 6

Eli Lilly and Company front cover, 18

National Drug Company . second cover, 360A, 360B

Chas. Pfizer and Company, Inc 354, 355, 356

Wm. P. Poythress 340B, 352A

A. H. Robins Company 328D

Roche Laboratories 15, 342, fourth cover

Schering Corporation 14A, 14B, 14C, 14D

Julius Schmid, Inc 350, 351

G. D. Searle 328B, 328C

Smith, Kline and French 1 1

Thomas Yates and Company third cover

JUNE 1970

363

) Si'ONSlDS HJLW3H

Support of emergency medical helicopter service by state medical
association at annual session fits national pattern of growing im-
portance of whirlybirds in rapid patient movement, Mississippi 1 s
CARE -SOM project is part of 300 helicopters now in service as air
ambulances in 2j$ states. Many hospitals have FAA-licensed helio-
ports on grounds or roofs, and some few have their own aircraft.
State's three helicopter bases serve 38 counties.

Fluoridation of water supplies marked 25th anniversary recently
with 88 million Americans in 4,800 communities having access to
cavity-fighting drinking water. First U.S. community to fluoridat
water was Grand Rapids, Mich., in 1945. Success of fluoridation hi
been outstanding and costs are minimal. American Dental Associatii
says it costs 10 cents iper person per year or only an additional $j
million to treat remaining un fluoridated water supplies.

The youngsters are the accident casualties at work. So says the
health Insurance Institute. A recent five-year study showed that
highest accident rate in office and factory is for those under age
20. Rate drops in age bracket 30-59 and tends to rise slightly fo
60-64 group. Falls are the greatest single source of injury, and
while sex is no factor in occurrence, men sustain more disabling
injuries than women, probably attributable to heavier work.

Pfizer Laboratories has marketed - with FDA approval - a new drug
for inoperable testicular cancer, an antibiotic tradenamed Mithraci
Derived from a soil organism of the Strep tomyces genus, the drug
is a potent cytotoxic substance which should be used only in hospi
tals. In 305 paiients, about 33 per cent had tumor masses to disa-
pear. Pfizer gives drug without charge when used for treatment of
indigent patients.

State legislatures are frugal with appropriations for teaching hos
pitals operated in conjunction with tax-supported medical schools.
Association of American Medical Colleges found that 34 teaching ho
pitals received only $169 million in state funds last year on xota
operating budgets of $560 million. Only one state provided more
than $10 million for a hospital. Highest budget for an institutio
was $39 million, and lowest was $5 million.

Volume XI
Number 7
July 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.

Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL CONSULTANT
Betty M. Sadler

• EDITORIAL ASSISTANT

INola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.
Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary-T reasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

original paper

Inherited Human Cancer 365 John F. Jackson, M.D.

SPECIAL ARTICLES

Radiologic Seminar XCVII
Ureteropelvic Junction

Obstruction 372 Nancy W. Burrow, M.D.

Medicine for the 70’s:

Decade of Decision 374 James L. Royals, M.D.

Constitution and By-Laws
of the Mississippi State

Medical Association 378 Annual Publication

EDITORIALS

Medicare’s Part C;

Danger, Dichotomy,

Anathema 387 Now, It’s HMO’s

State Legislation Is

Everybody’s Crisis 389 Solons and Medicine

CCS Goes to State Board

of Health 390 A Logical Move

Hellzapoppin’ on Drug

Abuse Bills 392 Washington

Tragedicomedy

Aspirin on Rx? Some

Say Yes! 394 30 Tons a Day!

Homicide Increases in the

United States 394 The Ultimate Violence

THIS MONTH

The President Speaking 386 ‘The Making of an M.D.’

Medical Organization 401 Ole Miss Medical Alumni

House Dedicated

Copyright 1970, Mississippi State Medical Association

S

A:

6

THE JOURNAL FOR JULY 1970

Illinois Plans
Postgraduate Course

The Department of Otolaryngology of the Uni-
versity of Illinois at the Medical Center will con-
duct a postgraduate course in laryngology and
bronchoesophagology Nov. 9-20, 1970.

The course is limited to fifteen physicians and
will be under the direction of Dr. Paul H. Holin-
ger.

Course headquarters will be at the Eye and
Ear Infirmary of the University of Illinois Hos-
pital, 1855 West Taylor Street, Chicago. Regis-
trants will attend animal demonstrations and
practice in bronchoscopy and esophagoscopy, di-
agnostic and surgical clinics, didactic lectures and
motion pictures. Visits to a number of Chicago
hospitals are also planned.

For further information, write to the Depart-
ment of Otolaryngology, Abraham Lincoln
School of Medicine of the College of Medicine,
University of Illinois at the Medical Center, P. O.
Box 6998, Chicago, 111. 60680.

Birth Defects
Symposium Scheduled

“Disorders of Glucose Metabolism in Chil-
dren,” the second annual Birth Defects Symposi-
um, will be Oct. 30-31, 1970, at the University
of Florida College of Medicine, Gainesville, Fla.

Sponsored by the university’s Institutional Di-
vision of Endocrinology and Metabolism and the
National Foundation-March of Dimes Birth De-
fects Center, the symposium will feature discus-
sions of diabetes mellitus, hypoglycemias of child-
hood and energy metabolism, as well as case pre-
sentations.

Guest faculty are Dr. Allan Drash, associate
professor of pediatrics, University of Pittsburgh,
and Dr. Donough O’Brien, professor of pedi-
atrics, University of Colorado. Dr. Arlan L. Ros-
enbloom, assistant professor of pediatrics and di-
rector of UF’s Birth Defects Center, is program
director. Meetings will be held in the second floor
auditorium of the College of Medicine.

Registration fees will be waived for interns
and residents. For additional information and
schedule of fees, please write Mrs. Betty L. How-
ard, Division of Postgraduate Education, J. Hillis
Miller Health Center, Gainesville, Fla. 32601.

r Tliff (Vs t

HOSPITAL

Hill Crest Foundation, Inc.

7000 5TH AVENUE SOUTH
Box 2896, Woodlawn Station
Birmingham, Alabama 35212
Phone: 205-836-7201

A patient centered
non-profit hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 45 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James K. Ward, M.D., F.A.P.A.

CLINICAL DIRECTOR:

Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

O st

HOSPITAL

BIRMINGHAM, ALABAMA

July 1970

jit Doctor:

LI and final implementation of Mississippi 1 s Medicaid program is
i ated for July 1 as plan observes six months milestone. Although
’licaid Commission has yet to release performance figures, payment
i junta, and claims volume, estimates are that providers* billing
>Locity will more than double with addition of prescription drugs.
i mining minor services, hitherto deferred, will also be offered.

Vendor drug program carries surprisingly small list of
mandatory generic prescription items. A vast majority
of the staxe's 704- licensed pharmacies are expected to
participate in program which will reimburse them costs
of Bx acquisition plus $1.50 professional fee.

I amine es of the American Board of Family Practice turned in excel-
; at showing on first try for certification. Of 2,678 physicians
;k±ng two-day exam in 3d centers, about &2 per cent became diplo-
:tes. Among those graduating from medical school in last 20 years,
laaost 96 per cent passed. New specialty board is unique in that
has no grandfather clause. Charter diplomates constitute only
out 3 per cent of nation's family physicians.

ssissippi's institutions of higher learning must establish a
aduate school of social work. So says Dr. Dorothy ft. Moore,
rector of the Interagency Commission on Mental Illness and Re-
rdation* Dr. Moore said present baccalaureate program needs
ster degree backup to assure full span of services offered by
ychiatrists, psychologists , and nurses now trained in state.

e British Medical Association has urged English physicians to
opt a policy of "noncooperation "with National Health Service,
e sharp break with socialized medicine came when NHS gave senior
ysicians only 15 per cent wage boost after 30 per cent was asked,
nior physicians and GP's received higher increase but specialists
re snubbed in wage dispute.

rkey. prime source of illicit narcotics, has offered to halt pro-
motion of opium if U.S. physicians sfop using opium derivatives.

A has replied that any proposal to siop use of morphine is move to
ny patients the most effective drug for relief of pain. AMA also
serted that even if Turkey clamped down on poppy- farming, traffic
heroin would probably continue as usual.

Executive Secretary

•/ v//V.

THE JOURNAL FOR JULY 1970

1 0

SMA Plans
November Meeting

The 64th Annual Meeting of the Southern
Medical Association, scheduled for Nov. 16-19 in
Dallas, is expected to be the largest and most
complete in the association’s history. The expan-
sive four day meeting, with each of 21 specialty
sections presenting its own program, will focus
upon new areas of medicine and scientific re-
search. Outstanding specialists and medical lead-
ers from many sections of the country will gather
to exchange knowledge, with over 300 speakers
participating in the interdisciplinary programs.

Dr. L. S. Thompson, Jr., general chairman,
heads the impressive list of Dallas members serv-
ing on the various committees which are charged
with the immense responsibility of making nu-
merous arrangements.

Officers of SMA include Drs. J. Leonard Gold-
ner (Durham, N. C.), president; Albert C. Espo-
sito (Huntington, W. Va.), president-elect;
J. Hoyle Carlock (Ardmore, Okla.), first vice-
president; and Linton H. Bishop, Jr. (Atlanta,
Ga.), second vice-president. Encompassing 16
southern states and the District of Columbia,

Southern Medical is America’s second largest gen-
eral medical organization, contributing the coun-
try’s largest general medical publication, the
Southern Medical Journal.

The Dallas Memorial Auditorium will house
the majority of meeting activities — scientific ses-
sions, business meetings, and the vast scientific
and technical exhibits. A number of panel discus- 1
sions and symposia of significant importance and
general interest will be presented. Several distin-
guished scientific groups to meet conjointly with
SMA are: The American College of Chest Phy-
sicians, Southern Chapter; the Flying Physicians .
Association; the Radiologic Society of North
America; and Southern Gynecological and Ob-
stetrical Society.

Again this year, the association will play host
to selected junior and senior medical students
from 34 medical schools throughout the SMA
sphere. This unique opportunity is designed to
impart to the students early in their careers the ^
value of continuing education.

The meeting will be open to all doctors of i i
medicine who are members of their county or j i
state medical societies, as well as to residents, in- |
terns, junior and senior medical students, nurses
and medical technicians. There will be no regis-
tration fee.

Guide Lauds CBS New York — TV Guide . commercialized mouthpiece
ast at Medicine for major networks^- lists the slanted CBS pro-
grams blasting medicine as being among the best
specials of the 1969-70 year. Consistent with this selection,
e magazine also picked the anti-South ” Anders on ville Trial” and
program on Black Panthers among the best of the season. The pub-
cation has an almost unblemished record of defending the networks1
sition on news editorializing and ”message” programming.

liege Pees Will Washington - Surveys released by U. S. Chamber
om Next Session of Commerce show that colleges and universities

will increase tuition fees substantially for the
70-71 session. Ivy League schools top list with $4,000 price tag
tuition and room and board. Median cost of tuition only at pri-
te institutions will run $2,500 and about $1,200 for in-state
udents at tax-supported schools. With medical schools equally
rd pressed, cost of M.D. degree continues upward price spiral.

. Incidence Atlanta - The U. S. Public Health Service Com-

ses in 1970 municable Disease Center reports that syphilis

shows a marked increase during the first four
aths of 1970. Incidence of the disease increased as much as 50
r cent in some areas of the nation, while the national rate was
over 10 per cent. Worst metropolitan area is New York City which
3 a 35 per cent increase in syphilis over 1969. The data also
sclose that incidence increase is notable among teenagers.

3tice, Congress, Washington - An intercabinet squabble over con-
V Hassle on Drugs trol of drugs has surfaced during committee hear-
ings on Capitol Hill on new Drug Abuse Control
gislation. Hearings are bogged down as Justice Department, now
3s of Bureau of Narcotics and Dangerous Drugs, wants more control,
eluding licensure of drug manufacture. HEW takes position that it
) medically-oriented and best suited for job. Justice would also
fce physicians keep records of all ”dangerous” drugs dispensed.

H Supports New Chicago - Spokesmen for AMA Committee on Al-
cohol Institute coholism and Drug Dependence support legislation

to create a new National Institute for Prevention
1 Control of Alcohol Abuse and Alcoholism in the NIH complex. Bill
old also recognize in federal statute that alcoholism is a disease
Lch can and should be treated. Another provision meeting AMA ap-
Dval is that treatment and control programs should be community-
3ed with federal grants for construction and staffing.

THE JOURNAL FOR JULY 1970

1 4

New Book Discusses
Disadvantaged Children

“A society genuinely concerned with educating
socially disadvantaged children cannot restrict it-
self merely to improving and expanding educa-
tional facilities ... it must concern itself with the
full range of factors contributing to educational
failure, among which the health of the child is of
primary importance,” says Dr. Herbert G. Birch,
New York pediatrician and psychologist.

He analyzes in depth this hitherto largely ig-
nored aspect of poverty in his new book, Disad-
vantaged Children: Health , Nutrition, and School
Failure , written in collaboration with Joan Dye
Gussow. This book offers the first full-scale anal-
ysis of the effects of health and nutritional depri-
vations on poor children.

Children suffer malnutrition before birth be-
cause their mothers are poorly fed and poorly de-
veloped physically, receive inadequate medical
care, and have children too often. After birth
these children continue to suffer because they
must live under many of the same conditions
which so severely affected their mothers through-
out their lives.

Doctors have long known that malnutrition
causes disease and seriously retards physical
growth. A series of recent studies strongly sug-
gest that malnourished children are also retarded
in their mental development. The available data,
new and old, on malnutrition, morbidity, and
medical care among children of poor families in
this country indicates that “the quality of their
lives puts these children at risk as learners either
by permanently impairing their capacity to learn
or by interfering with the orderly acquisition of
knowledge.”

From birth to one year old, the human brain
goes from 25 per cent to 70 per cent of its adult
weight; by age 4 it is almost completed struc-
turally. Therefore, the younger the child, the
more significantly starvation affects his brain.
Even relatively minor deprivation before birth
and during the early years may have permanent
effects far in excess of severe restrictions later in
life.

Malnourished children are apathetic and irri-
table, and they lose the child’s normal curiosity
and desire for exploration. After being properly
fed for a while, their normal responsiveness is
regained. But, the duration of the period of un-
dernourishment affects subsequent mental devel-
opment.

LEONARD WRIGHT SANATORIUM

BYHALIA, MISSISSIPPI 3861 I TELEPHONE A/C 601, 838-2162

LEONARD D. WRIGHT, SR., B.S., M.D., PSYCHIATRY

• Established in 1948. Specializing in the treatment of ALCO-
HOLISM and DRUG ADDICTIONS with a capacity limited
to insure individual treatment. Only voluntary admissions ac-
cepted.

• Located 25 miles S. E. of Memphis-Highway 78 on 20 acres
of beautifully landscaped grounds sufficiently removed to
provide restful surroundings.

• The Sanatorium is approved by The Commission on Hospital
Care in the State of Mississippi.

MISSISSIPPI STATE MEDICAL ASSOCIATION

1 5

cAny Questions qbout
^Bliie? Sl\iepld?

Call on these people for the answers .

C. T. Walker
Director

Charles Caffey, Area A
Field Representative
1 1 1 Lilac Drive
1. eland, Mississippi
Phone: 686-4753

Warren Hd wards, Area B
Field Representatis e
530 F. Woodrow Wilson
Jackson, Mississippi
Phone: 366-1422, Fxt. 42

Max Gilliland, Area C
Field Representative
620 South 28th Avenue #422
Hattiesburg, Mississippi
Phone:582-0479

G. 1 . Franciskato
Ma nager

Cynthia Gordon
Supers isor

Mississippi Hospital and Medical Service P. O. Box 1043 Jackson, Mississippi 39205

NHLI Plans Sudden
Cardiac Death Studies

The National Heart and Lung Institute,
through its Myocardial Infarction Program, has
awarded the first of a series of contracts for a
program of research on sudden cardiac death.
Sudden cardiac death, or death before hospitali-
zation, accounts for about one-half of the almost
600,000 annual deaths from arteriosclerotic heart
disease. While an improvement in the early avail-
ability of medical care will somewhat reduce this
death toll, the large number of very sudden and
very early deaths necessitates a better under-
standing of the acute disease process and the de-
velopment of new modes of therapy.

The contractors and their awards for the first
year are: the University of Miami, Miami, Fla.
($284,896), Johns Hopkins University, Balti-
more, Md. ($157,000), Mount Zion Hospital
and Medical Center, San Francisco, Cal. ($68,-
500), and Emory University, Atlanta, Ga. ($14,-
575). Several additional contracts will be an-
nounced in the near future.

These contracts are designed to: identify

“trigger” factors that convert coronary athero-
sclerosis, the underlying disease process which
may have been quietly present for many years,
into a full-blown attack; identify premonitory
signs and symptoms that may warn the patient or
his physician of an impending attack so that mea-
sures can be initiated to abort the threatened epi-
sode or, failing that, hospitalize the patient be-
fore it occurs; identify factors that characterize
the person at high risk of sudden, unexpected
death. Epidemiological studies have quantified
many of the factors which increase susceptibility
to coronary heart disease — for example, high
blood pressure, elevated blood lipids, cigarette
smoking, obesity, electrocardiographic abnormali-
ties, and sedentary habits. It may be possible to
refine this “coronary profile” and to recognize
other factors to identify prime candidates for
rapidly lethal heart attacks.

The contracts are also designed to identify the
physiological mechanisms responsible for acute
heart attack and sudden death and to correlate
them with anatomical and pathological changes;
and to determine practical methods of treatment
for the very early stages of a heart attack.

A major facet of the contracts which have
been awarded is the collaborative study of corre-
lations between autopsy findings and antecedent
events in sudden cardiac death victims. The four
contracts all provide for a common core of autop-
sy and interview data.

Brief Summary of Prescribing Information-

9-9/22/69. For complete information consult
Official Package Circular.

Indications: Essential hypertension. Use cau-
tiously in patients with renal insufficiency,
particularly if they are digitalized.
Contraindications: Anuria, oliguria, active
peptic ulceration, ulcerative colitis, severe de-
pression or hypersensitivity to its components
contraindicates the use of Salutensin.
Warnings: Small-bowel lesions (obstruction,
hemorrhage, perforation and death) have
occurred during therapy with enteric-coated
formulations containing potassium, with or
without thiazides. Such potassium formula-
tions should be used with Salutensin only
when indicated and should be discontinued
immediately if abdominal pain, distension,
nausea, vomiting or gastrointestinal bleeding
occurs. Use cautiously, and only when deemed
essential, in fertile, pregnant or lactating pa-
tients. Use in Pregnancy: Thiazides cross the
placenta and can cause fetal or neonatal
hyperbilirubinemia, thrombocytopenia,
altered carbohydrate metabolism and possibly
electrolyte disturbances. Fatal reactions may
occur with reserpine during electroshock
therapy; discontinue Salutensin 2 weeks be-
fore such therapy. Increased respiratory
secretions, nasal congestion, cyanosis and
anorexia may occur in infants born to reser-
pine-treated mothers.

Precautions: Azotemia, hypochloremia, hypo-
natremia, hypochloremic alkalosis and hypo-
kaliemia (especially with hepatic cirrhosis
and corticosteroid therapy) may occur, par-
ticularly with pre-existing vomiting and diar-
rhea. Potassium loss or protoveratrine A may
cause digitalis intoxication. Potassium loss
responds to potassium-rich foods, potassium
chloride or, if necessary, discontinuation of
therapy. Stop therapy if protoveratrine A
induces digitalis intoxication. Serum am-
monia elevation may precipitate coma in
precomatose hepatic cirrhotics. Discontinue
therapy 2 weeks before surgery or if myo-
cardial irritability, progressive azotemia or
severe depression occur. Exercise caution in
patients with chronie uremia, angina pec-
toris, coronary thrombosis or extensive cere-
bral vascular disease or bronchial asthma and
in those with a history of peptic ulceration or
bronchial asthma; in post-sympathectomy pa-
tients; in patients on quinidine; and in pa-
tients with gallstones, in whom biliary colic
may occur. Patients who have diabetes
mellitus or who are suspected of being pre-
diabetic should be kept under close observa-
tion if treated with this agent.

Adverse Reactions: Hydroflumethiazide: Skin
rashes (including exfoliative dermatitis), skin
photosensitivity, urticaria, necrotizing angiitis,
xanthopsia, granulocytopenia, aplastic
anemia, orthostatic hypotension (potentiated
with alcohol, barbiturates or narcotics), aller-
gic glomerulonephritis, acute pancreatitis,
liver involvement (intrahepatic cholestatic
jaundice), purpura plus or minus throm-
bocytopenia, hyperuricemia, hyperglycemia,
glycosuria, malaise, weakness, dizziness, fa-
tigue, paresthesias, muscle cramps, skin rash,
epigastric distress, vomiting, diarrhea and
constipation. Reserpine: Depression, peptic
ulceration, diarrhea, Parkinsonism, nasal stuf-
finess, dryness of the mouth, weight gain,
impotence or decreased libido, conjunctival
injection, dull sensorium, deafness, glaucoma,
uveitis, optic atrophy, and, with overdosage,
agitation, insomnia and nightmares. Proto-
veratrine A: Nausea, vomiting, cardiac ar-
rhythmia, prostration, blurring vision, mental
confusion, excessive hypotension and brady-
cardia. (Treat bradycardia with atropine and
hypotension with vasopressors.)

Usual Dose: 1 tablet b.i.d.

Supplied: Bottles of 60, 600, and 1000 scored
50 mg. tablets.

Salutensin

hydroflumethiazide, 50 mg./reserpine,
0.125 mg. protoveratrine A, 0.2 mg.

BRISTOL

BRISTOL LABORATORIES
Division of Bristol-Myers Company
Syracuse, New York 13201

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

July 1970, Vol. XI, No. 7

Inherited Human Cancer

JOHN F. JACKSON, M.D.

Jackson, Mississippi

Any discussion of the genetic aspects of human
cancer should include tumors in general rather
than just malignant tumors, since some benign
inherited tumors have rather definite relationships
to the development of malignancy. The genetics
of tumors involves two broad areas. One aspect is
cytogenetics, which includes those things that can
be examined with the microscope, such as chro-
mosome analysis and buccal smears from which
the sex chromosome patterns can be inferred.
The other aspect is Mendelian inheritance, in
which there are defects of specific genes that lie
at some particular point (locus) on a specific
chromosome. Gene defects can not be seen using
the microscope, but their presence can be investi-
gated by doing family studies (pedigrees) to de-
termine inheritance patterns.

Mendelian genetics has three rather simple pat-
terns of inheritance: autosomal dominant, auto-
somal recessive, and X-linked (or sex-linked).
Autosomal refers to the fact that the gene lies on
a chromosome other than a sex chromosome. In
man there are a total of 46 chromosomes with
22 pairs of autosomes and two sex chromosomes
in all somatic cells. In the female, the sex chro-

From the Departments of Preventive Medicine and Medi-
cine, University of Mississippi School of Medicine.
Presented December 3, 1969, in the Clinical Cancer Pro-
gram, Wednesday Cancer Conference Series.

mosomes consist of two X chromosomes, and in
the male there is one X chromosome and one Y
chromosome.

While some inherited tumors are malig-
nant at the time they first appear , other in-
herited disorders produce benign tumors
which later may become malignant. The au-
thor includes both types in his discussion.
He considers in depth the areas of cyto-
genetics and Mendelian inheritance.

In autosomal dominant gene transmission, any-
one who inherits the abnormal gene is affected.
He transmits this gene to 50 per cent of his chil-
dren on the average because of the fact that he
must give them one or the other of his two chro-
mosomes of each pair. If the abnormal gene is
transmitted, then the offspring gets the disorder.
If the normal gene is transmitted, the child does
not get the disorder, assuming that the spouse is a
normal individual and does not carry the same
gene. Since most inherited tumors are relatively
uncommon, usually only one spouse has the dis-
order (Figure 1 ) .

Neurofibromatosis is inherited in an autosomal
dominant fashion. In this disorder, there are be-

JIJLY 1970

365

INHERITED CANCER / Jackson

nign tumors protruding from the surface of the
skin. There may be literally hundreds covering
an individual or there may be only one or two. In
about 5 to 10 per cent of affected individuals, a
benign neurofibroma will be transformed ulti-
mately into a sarcoma. Peutz-Jeghers syndrome is
also inherited in simple autosomal dominant fash-
ion. This disorder has associated melanin-pig-
mented spots about the lips with benign polyps
of the intestine. This disorder does not appear to
have any propensity to malignant transformation.
Hyperkeratosis palmaris and plantaris, on the
other hand, has a rather high incidence of associ-
ated esophageal carcinoma.

Familial polyposis of the colon is also inherited
as a simple autosomal dominant, but carries a
much more grim prognosis. In familial polyposis
there are literally myriads of small polyps scat-
tered throughout the mucosa of the entire colon.
If the colon is not removed, most patients with
this disorder will have malignant transformation
of one or more polyps by the age of 40. Thus
here is illustrated an array of benign tumors in-
herited in simple autosomal dominant fashion,
but with great variation in predisposition to ma-
lignant transformation.

OTHER DISEASES

There are other diseases such as retinoblas-
toma, usually inherited as an autosomal domi-
nant, though there are sporadic cases which are
not inherited. There is also Gardner’s Syndrome
in which there are polyps of the colon, oste-
omas, fibromas, and epidermal cysts. In poly-
endocrine adenomatosis there may be tumors of
the pituitary, of the adrenal cortex, occasionally
of the thyroid and frequently of the parathyroid.

AUTOSOMAL DOMINANT GENE TRANSMISSION

AFFECTED NORMAL

50% AFFECTED 50% NORMAL

Figure 1

Peptic ulcer is frequently associated, and the Zol-
linger-Ellison syndrome of peptic ulcer associated 1
with gastrin-secreting pancreatic tumor may be
one facet of polyendocrine adenomatosis. In ad-
dition, there are hereditary multiple exostoses,
multiple nevoid basal cell carcinoma, medullary
thyroid carcinoma with amyloid, hereditary ade-
nocarcinomatosis of the colon and uterus, and
pheochromocytoma as other examples of tumors
inherited in autosomal dominant fashion.

PROBABLE TRANSMISSION

Once any of these diseases appears in an indi-
vidual, then the expectation is for him to transmit
the disorder to 50 per cent of his children. In
small sibships, there are not always exactly 50
per cent affected, just as one can flip a coin and
have heads appear several times in succession.
Similar skewed distribution may occur with dom-
inant disease in one individual family, yet the sta-
tistical expectancy in large numbers at risk is for
50 per cent of the children to be similarly affect-
ed.

The next Mendelian inheritance pattern for
discussion is sex-linked recessive gene transmis-
sion. By sex-linked is meant that the gene is lo-
cated on an X chromosome, of which the female
has two and the male has one. The reason that
genes on the X chromosome are inherited in a
different pattern is because the small Y chromo-
some in males leaves most of the genes on the
X chromosome unpaired, whereas, the normal
female has two completely-paired X chromo-
somes. Therefore, if an abnormal gene is present
on that part of the X chromosome that is un-
paired by the Y chromosome, then all of the
males carrying this gene will be affected. If the
abnormal gene is on one of the X chromosomes
in the female and paired by a normal X chromo-
some, the disorder will not be manifested.

RESULTANT PATTERN

The resultant pattern is that the affected male
transmits his abnormal gene to all of his daugh-
ters who then are carriers. They are not affected
by this disorder because they have a normal gene
on their other X chromosome. The affected fa-
ther does not transmit the disorder to any of his
sons because in order form them to be sons, they
have to get his Y chromosome; otherwise they
would have been daughters if they had received
his X chromosome. In the next generation, a fe-
male carrier married to a normal male has 50
per cent carrier daughters, and 50 per cent nor-
mal who can not transmit the gene to the next

366

JOURNAL MSMA

SEX-LINKED RECESSIVE GENE TRANSMISSION

AFFECTED

MALE

X Y

NORMAL

FEMALE

X X

100%

CARRIER

DAUGHTERS

100%

NORMAL

SONS

NORMAL

MALE

X Y

CARRIER

FEMALE

X X

50%

50%

50%

50%

CARRIER NORMAL AFFECTED NORMAL

DAUGHTERS SONS

Figure 2

generation. Fifty per cent of the female carrier’s
sons will be affected and 50 per cent will be nor-
mal. Thus the pattern of transmission in a pedi-
gree is that an affected grandfather has affected
grandsons, and that there are only males affected
(Figure 2) .

RARE TRANSMISSIONS

Since most of these disorders are rare, it is un-
usual for a carrier female to marry an affected
male. In such a case, affected females with ab-
normal genes on both X chromosomes could re-
sult. This is actually an over-simplification, since
some females with only one abnormal X-linked
gene may be more or less affected. This is due to
the random inactivation of one of the X chromo-
somes to form the sex-chromatin body occurring
as a normal event in all females, according to the
Lyon hypothesis. Most female carriers are unaf-
fected. Ichthyosis vulgaris is X-linked in trans-
mission. There is some keratin build-up which is
similar to that in hyperkeratosis palmaris and
plantaris, but there is no increased incidence of
malignancy in this disorder. Agammaglobuline-
mia of the Bruton type, in which there is failure
to develop gammaglobulins, is inherited in

X-linked fashion, and there is a high incidence
of associated leukemia.

The third and last pattern of Mendelian in-
heritance is that of autosomal recessive gene
transmission. The gene is on an autosome, a non-
sex chromosome. It is recessive, in that an indi-
vidual who carries only one abnormal gene is not
affected by the disorder. He must have abnormal
genes at this particular locus on both chromo-
somes to be affected. The most common marriage
producing children affected with autosomal re-
cessive disorders is that between two asympto-
matic carrier parents. Therefore as one looks at
the pedigree, there are usually multiple sibs in-
volved in one generation only. The disorder is not
transmitted directly from one generation to an-
other; it affects males and females in equal ratio;
and on the average in this particular mating, one
in four offspring will be affected. Two out of four
will be asymptomatic carriers. One out of four
will be normal, not even carrying the gene, and
cannot transmit it to the next generation. An af-
fected individual married to a carrier will pro-
duce 50 per cent affected and 50 per cent carrier
individuals. A carrier married to a normal pro-
duces half carriers and half normal. An affected

L'i

.>

$

: ‘T

JULY 1970

367

INHERITED CANCER / Jackson

spouse married to a normal person will produce
all carrier individuals. Therefore, the gene is often
transmitted from one generation to another with-
out the disorder ever appearing. This is why peo-
ple are often astonished when they are told that
they have an inherited disorder, since it has never
before appeared in the family (Figure 3).

XERODERMA PIGMENTOSUM

Xeroderma pigmentosum is a disorder inherit-
ed in simple autosomal recessive fashion in which
all affected individuals develop skin carcinomas
in the exposed areas. Ataxia telangiectasia is an
interesting disorder readily recognized by multi-
ple telangiectases about the conjunctivae that may
extend over the bridge of the nose or the upper
part of the face and characteristic ataxic signs of
cerebellar disease. One of our patients was ad-
mitted to the hospital at age 19 because of per-
sistent nausea and vomiting. An enormous polyp-
oid mass filled the stomach. At the time of sur-
gical exploration the mass was a gastric adeno-
carcinoma with typical signet ring cells on histo-
logic examination. She had a feeding gastrostomy
but soon expired. At autopsy there were multiple
metastases and no germinal centers in the lymph

nodes. She also had a lung abscess and lacked
gamma A immunoglobulins. Gamma A is the
immunoglobulin that is secreted into the respira-
tory tract and is really the first line of defense
against pulmonary invasion. Her gamma G and
gamma M immunoglobulins were actually higher
than normal and her parents and her unaffected
sibs all had normal levels of all three immuno-
globulin classes.

Our patient was the youngest of 12 sibs, five
of whom had ataxia telangiectasia. All of the
other affected sibs were dead. Her next older sis-
ter, who had died at the age of 21, also had a
gastric adenocarcinoma histologically indistin-
guishable from that of our patient. It had been
previously reported that individuals with ataxia
telangiectasia had a predisposition to leukemias
and lymphomas. We feel that with the demon-
stration of gastric adenocarcinoma in two young
sibs that we need to consider that ataxia telan-
giectasia predisposes to malignant tumors in gen-
eral, not just to leukemias and lymphomas. Thymic
dysplasia and a high percentage of chromosome
breakage and rearrangement of chromosomes in
tissue culture are also characteristic of ataxia tel-
angiectasia. In addition, the peripheral blood
lymphocytes fail to respond adequately to stimu-
lation in tissue culture.

AUTOSOMAL RECESSIVE GENE TRANSMISSION

CARRIER CARRIER AFFECTED CARRIER

PARENTS

25% 50% 25%

AFFECTED CARRIER NORMAL

50% 50%

AFFECTED CARRIER

Figure 3

368

JOURNAL MSM A

A

I -3

B

4-5

n r

V

Ji

m

m

6 -12 and X

i r

D

13-15

MM SI 2S IS firar^ir

t

16

17-18

F

19-20

2l-22and Y

fit — tsn <& — »

Xx

4A

A*

V'.'

.1 * . * P;

i

A * A . M

„ ' **«

4 ^ I

Figure 4. Normal male karyotype.

In addition to ataxia telangiectasia, two other
disorders inherited in an autosomal recessive pat-
tern also have excessive chromosome breakage
and rearrangement. One is Bloom’s syndrome, or
telangiectatic dwarfism, and the other is Fanconi’s
congenital anemia. These two disorders share
with ataxia telangiectasia the predisposition to the
development of leukemias. Chromosome abnor-
malities are an integral part of the development
of malignant tumors. It is interesting to speculate
that in Bloom’s syndrome, Fanconi’s anemia, and
ataxia telangiectasia, the predisposition to chro-
mosome breakage allows for genetic variability
and ultimately the evolution of malignant tumors.

CYTOGENETICS

Cytogenetics is concerned with what we can
see in the microscope. Chromosome analysis is
performed using an ordinary light microscope.
The electron microscope is not necessary to study
human chromosomes. Since the largest chromo-
some is about as long as the diameter of a red
blood cell there is no difficulty in seeing this in
the ordinary light microscope using oil immersion.
A photograph of the chromosomes scattered
about the cell is enlarged to 8 x 10. Each chro-
mosome is cut out with scissors, paired with its

homologue and arranged in descending size to
form what is known as a karyotype. Figure 4 is a
normal male karyotype with the autosomes to
the left of the vertical line and the sex chromo-
somes to the right, in this case one X and one Y
chromosome. The normal female karyotype is the
same except that the sex chromosomes are two
X chromosomes (Figure 4).

One fairly frequent chromosome abnormality
produces gonadal dysgenesis or Turner’s syn-
drome in which there are only 45 chromosomes
and only one sex chromosome, an X chromo-
some. Turner's syndrome characteristically pre-
sents as a phenotypic female who is short of
stature, has an increased carrying angle of the
arms, frequently a webbed neck, has fibrous tis-
sue streaks for ovaries and as a result of the lack
of ovarian stimulation fails to menstruate. Not all
individuals with Turner’s syndrome have exactly
the same type of chromosomal abnormality.
Many have a mixture (mosaic) of cells with some
that are XO and some XX. In rare cases the
chromosome constitution includes some cells with
XY male sex chromosomes. Individuals who have
the phenotypic Turner syndrome but have some
XY cells, have a very high incidence of tumors
of the ovary, usually gonadoblastoma. This is a

369

JULY 1970

INHERITED CANCER / Jackson

special indication for exploration and removal of
the streak ovaries.

Chromosome analysis on another of our pa-
tients showed he had only 45 chromosomes and
was missing a chromosome in the C group. He
had myelofibrosis with myeloid metaplasia, which
is considered to be a premalignant lesion by many
in that people with myeloid metaplasia frequent-
ly terminate with acute leukemia. Other cells
from that same individual contained 90 chromo-
somes instead of 45 chromosomes. In all prob-
ability the 90 chromosome cells evolved from the
abnormal 45 chromosome cell line by polyploid-
ization. In about 0.5 per cent of the cells that we
see in mitosis from normal peripheral blood cul-
tures there is polyploidy, i.e., having 92 chromo-
somes or some other multiple of the normal num-
ber. At some time, a polyploid cell went through
the process of chromosome duplication without
an intervening mitosis. This is one way in which
tumors develop their great genetic heterogeneity
when the original chromosome number is abnor-
mal, so that in this particular case there were
two chromosomes missing from the 6 to 12 group.

Chronic myelogenous leukemia is the only ma-

lignant tumor associated with a specific chromo-
some abnormality. The abnormality is known as
the Philadelphia one (Ph 1) chromosome, named
for the laboratory in which it was discovered. The
Ph 1 chromosome is one of the 21-22 group
which has suffered a deletion, or breakage with
loss of about one-half to two-thirds of its long
arms. Most of the cases of chronic myelogenous
leukemia have the Philadelphia one chromosome,
and those who are Ph 1 positive have been
shown to be more responsive to therapy than the
ones who are negative. It occasionally appears in
duplicate during the time in which chronic my-
elogenous leukemia may be transformed into
acute leukemia. The acute leukemias, on the oth-
er hand, frequently have abnormal chromosome
numbers but there has been no specific pattern.
One of our cases of acute leukemia had a modal
number of 47 and there was an extra chromo-
some belonging to the G group. Sometimes there
may be 45 chromosomes, or 48, or some other
number around the normal modal number of 46.

Malignant solid tissue tumors routinely exhibit
chromosome abnormalities to a marked degree.
Figure 5 is a karyotype from an individual with
carcinoma of the lung and was prepared directly
from a pleural effusion. It shows typical findings
for malignant tumors, the wrong chromosome

■mm — i I — m

13-15

16-18

i 19 — 20 1

Figure 5 . Karyotype of cell from pleural effusion clue to carcinoma of the lung.

370

JOURNAL MSMA

number (aneuploidy) obviously containing too
many chromosomes, and there are incorrect num-
bers within the groups. Finally there are individu-
al chromosomes called marker chromosomes
which are different in size or shape from any of
the normal chromosomes. They usually develop
by the process of translocation involving breakage
of two chromosomes with rejoining to form an
abnormal chromosome. Occasionally there are
chromosomes that look like two round dots stuck
together. These are minute chromosomes that ap-
pear frequently in malignant central nervous sys-
tem tumors of children. We have seen such mi-
nute chromosomes in a dysgerminoma from an
8-year-old child. The total chromosome number
may be extremely high. Chromosome analysis of
cells from effusions can be of help in individuals
who are suspected of having malignancies as the
cause for their effusions (Figure 5).

One of the things that has interested us for the
past several years is why tumor cells become
polyploid. It is not often that we have an oppor-
tunity to examine a biochemical mechanism for
cytologic disturbances, but normal human leuko-
cytes can be induced to become polyploid by
treating them with /J-mercaptoethanol. Cultures
of normal human leukocytes treated with mer-
captoethanol contain binucleate cells in some of
which the two nuclei fail to separate, producing a
striking resemblance to Reed-Sternberg cells
seen in Hodgkin's Disease. Sometimes the chro-
mosomes duplicate but fail to separate producing
an endoreduplication in which the two like chro-
mosomes lie side by side. Rarely a cell will under-
go two chromosome replications without an inter-
vening mitosis, producing an octoploid mitosis
having four times the normal number of chromo-
somes. Occasionally some of the chromosomes
are seen to be greatly fragmented.

Thus in tissue culture we have induced things
that occur spontaneously in tumors. If these ob-
servations applied only to mercaptoethanol they
would be of little significance because mercapto-
ethanol is not a normal physiologic metabolite nor

is anyone apt to be exposed to large concentra-
tions since it has such a foul odor. But the amino
acid cysteine also contains a sulfhydryl group.
Cysteine can be transaminated to /3-mercapto-
pyruvate, which also induces polyploidy in nor-
mal human leukocytes. We have been working on
a hypothesis which supposes that with a decrease
in enzymes that ordinarily remove mecaptopyru-
vate, that this physiologic intermediate might ac-
cumulate as a result of the normal metabolism of
cysteine. Cysteine is also converted to cysteamine
by decarboxylation in man. Cysteamine is one of
the best known radio-protective agents, yet it also
will induce polyploidy. These cytologic effects are
probably not the process by which tumors are
initiated, but may be one of the pathways by
which tumors progress, perhaps explaining why
individual cancer cells become polyploid.

Some disorders that are inherited in simple
Mendelian fashion produce benign tumors which
later may become malignant. Other inherited tu-
mors are malignant at the time they first appear.
Pedigree analysis allows differentiation of the spe-
cific inheritance pattern in many cases. Cyto-
genetic study can confirm the diagnosis in chronic
granulocytic leukemia and may identify cancer as
a cause for effusions. Correlative biochemical
studies of enzymes and chromosome analysis may
yield clues to the pathogenesis of chromosome
abnormalities in malignant tumors. ***

2500 N. State St. (39216)

REFERENCES

1. Haerer, A. F.; Jackson. J. F.; and Evers, C. G.:
Ataxia-Telangiectasia With Gastric Adenocarcinoma.
JAMA 210:1884. 1969.

2. Jackson. J. F.: Chromosome Analysis of Cells in Ef-
fusions From Cancer Patients, Cancer 20:537 (April)
1967.

3. Jackson, J. F.; and Lindahl-Kiessling, K.: Action of
Sulfhydryl Compounds on Human Leukocyte Mitosis
in Vitro. Exper. Cell Res. 34:515, 1964.

4. Lynch. H. T.: Hereditary Factors in Carcinoma, New
York. Springer-Verlag Inc., 1967.

5. McKusick, V. A.: Mendelian Inheritance in Man, ed.
2, Baltimore, The Johns Hopkins Press, 1968.

USUAL AND CUSTOMARY

The plumber, called to unstop the kitchen sink, presented his
bill for $25 to the housewife’s dismay and astonishment.

“Why, my doctor only charges $8 a visit for treating my child,”
she complained.

“Yes, I know,” replied the plumber. “That’s what I charged
when I was a pediatrician.”

JULY 1970

371

Radiologic Seminar XCVII
Ureteropelvic Junction Obstruction

NANCY W. BURROW, M.D.

Brandon, Mississippi

There are three anatomical points of narrow-
ing in the normal course of the ureters; 1) at the
ureteropelvic junction, 2) where the ureter cross-
es the iliac vessels, and 3 ) at the ureterovesical
junction.3 The first of these will be considered
with conditions leading to obstruction at this
point.

By far the most frequent cause of UPJ (ure-
teropelvic junction) obstruction is a congenital
stricture or narrowing or an abnormal vessel.2
This is the most common urologic problem in in-
fants and children, so commonplace in fact that a
flank mass in a child should be considered a hy-
dronephrotic kidney until proven otherwise. Se-
vere degrees of obstruction may give rise to early
symptoms and findings. Milder degrees may not
become clinically apparent until adult life.

There is a distinct tendency for this condition
to be a bilateral occurrence, but the dilatation
may be less marked on one side so that only one
kidney need be corrected. Minimal degrees of
pyelectasis are clinically important, however, as
this may be the basis for recurring infection.

Opinions differ greatly concerning types and
causes of congenital obstruction of the uretero-
pelvic junction and when one considers the fact
that at operation the nature of the obstruction
sometimes cannot be determined, it seems too
much to expect etiological information from a
urogram. Mainly the urogram is of diagnostic

-'ponsored by the Mississippi Radiological Society. From

he Department of Radiology, Rankin General Hos-
pital.

value only in the broad sense of recognition of
the obstructive condition at the UPJ.1 However,
occasionally the urogram will distinguish between
a high, nondependent insertion of the ureter into
the renal pelvis and a ureter in the normally de-
pendent position but narrowed or obstructed from
stenosis, stricture or neuromuscular phenomena.
Anomalous vessels crossing the area may be
demonstrated with urogram or more definitely by
aortography.

On a plain film of the abdomen most frequent-
ly no abnormality is noted. After injection of the
contrast medium there can be a wide variation in
the degree to which renal function has been al-
tered. Good concentration of the medium may
appear promptly; there will, however, be a di-
lated renal pelvis without obvious cause. The
pyelectasis may be disproportional to the caliec-
tasis; the calyces frequently remain sharp and
well-formed. The ureter will be of a normal cali-
bre.

This would appear to be a rather straight-for-
ward radiographic diagnosis, but there is one pit-
fall for all of us. If there is obstructive uropathy
at some lower level in the ureter and the study is
concluded prior to ureteral filling, the films will
resemble UPJ obstruction. Advanced vesicoure-
teral reflux has been reported to simulate UPJ
obstruction due to continued pelvic filling from
reflux rather than obstructive disease.4

The point to be gained here is that a diagnosis
of UPJ obstruction should be substantiated with
the visualization of a normal ureter distal to the

372

JOURNAL MSMA

Figure 1. Radiograph ten minutes after IV injec-
tion of contrast media shows delayed function on the
right with a normal left upper renal tract.

UPJ. If the obstruction is complete or advanced,
retrograde studies may be necessary to demon-
strate the normal ureter.

Conditions which may present a similar radio-
graphic picture would include a stone lodged at
the UPJ; tumors, both intrinsic and extrinsic to
the collecting system; aortic aneurysm, and some
inflammatory lesions.5

In general, mild degrees of ureteropelvic ob-
struction with pyelectasis and little or no caliec-
tasis are best left alone. Indications for surgery
include pain, calculi infection and destruction of
renal substance. In borderline cases a conserva-
tive approach is best with yearly urograms to de-
termine if the condition is progressing.

Whenever a kidney is approached surgically
for a stone, the surgeon should consider the possi-
bility of associated obstruction of the uretero-
pelvic junction as an etiological factor in calcu-
lous formation.1

Success of operation on the ureteropelvic junc-
tion is evaluated on the basis of clinical and uro-

Figure 2. Delayed radiograph on the same patient
demonstrating hydronephrotic right kidney secondary
to obstruction at the ureteropelvic junction. Note that
the left upper renal tract has completely drained.

graphic results. The patient may become asymp-
tomatic yet the postoperative urograms may show
little or no change. On the opposite extreme
some cases may have a normal appearing post-
operative study.

Regardless of etiology, the clinical importance
of prompt diagnosis of a UPJ obstruction is ob-
vious as this condition is amendable to surgery
with salvage of the kidney. ***

Rankin General Hospital (39042)

REFERENCES

1. Emmett, John L.: Clinical Urography. Philadelphia,
W. B. Saunders Company, 1964, p. 308-357.

2. Kaufman, Joseph and Maxwell, Morton: “Ureteral
Varices.” American Journal of Roentgenology, Ra-
dium, Therapy and Nuclear Medicine 92:346-350.
1964.

3. Kerr, H. Dabney and Gillis, Carl: The Urinary Tract.
Chicago, Yearbook Publishers Inc., 1944.

4. King, Lowell R.: Apparent Ureteropelvic Obstruction
Caused by Vesicoureteral Reflux. Illinois Medical
Journal 133:711-715, 1968.

5. Wesson. Miley B.: Urologic Roentgenology. Philadel-
phia, Lea and Febiger. 1946.

JULY 1970

373

Medicine for the 70’s:
Decade of Decision

JAMES L. ROYALS, M.D.

Jackson, Mississippi

The delivery system which purveys medical
care to Americans is on trial. Agencies of govern-
ment engaged in care financing are attacking the
system. A variety of proposals for radical change
are heard in the halls of Congress. Insurance and
Blue plans are introducing subtle influences upon
it. And we ourselves in medical organization, the
staunchest advocates of the system, are raising
questions about it.

As if this were not enough to strain the fabric
of medical organization, substantial forces from
the mass media and social interest groups appear
to have decided that any ill of mankind, whether
physical, mental, or otherwise, is somehow re-
lated to the real and fancied deficits of our medi-
cal care delivery system. The decade of the '60’s
brought change in medical care financing with
Medicare and Medicaid, and the administration
of these programs has exerted an impact upon
delivery patterns.

So it should come as no surprise that I have
found unrest among my colleagues and a creep-
ing insecurity in our ranks. We have discovered
that it is not easy to adjust to change, especially
when much of it is brought upon us by outside
sources.

I do not or could not claim perfection for our
care delivery system. Growing older, I confess to
an increasing discomfort with change, and I find
myself resisting it more frequently. But we must
recognize that we are living in a dynamic time, a
time of rapid and dramatic change, of new and
varied social forces, of miraculous technology,
and of troubled political balance in a volatile
world.

President. Mississippi State Medical Association, 1969-

1970.

i :ad before the House of Delegates, 102nd Annual Ses-
sion, Biloxi, May 11-14, 1970.

We must not only adjust to change, but we
must also exercise leadership that will conceive
and direct the course of changes within medicine

The cave delivery system is on trial, says
the 1969-70 president of the association.
The challenges are great, and medical or-
ganization must work together or fail in the
responsibilities it has assumed. Physicians
must be prepared to make substantial contri-
butions of time and substance to preserve a
pluralistic delivery system and to insure the
best medical care for all Mississippians and
for all Americans.

and medical care delivery. An inquisitive out-
reach in a constant search to improve and a will-
ingness to experiment with promising change are
hallmarks of medical progress. Let us look to the
young for increasing leadership responsibility in
our search for better health care. Toward this
end, I applaud the move to bring medical stu-
dents into more active participation in medical af-
fairs.

It has become forcefully apparent that there is
a serious shortage of medical manpower in our
nation. Compounding the problem has been a
vast expansion of the care purchasing base
through government-financed programs. And in-
creased demand for medical services results not
only from increased ability to purchase but also
from rising levels of health education and from
the deceptively simple fact that there are more of
us to consume care.

Mississippi has the lowest physician-to-popula-
tion ratio of any state in the union. Nationally,
there is a physician for every 750 Americans. In

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JOURNAL MSMA

our state, we have one physician for every 1,400
Mississippians. The ratios for other members of
the health care team are similar and we stand at
the national midpoint on medical facilities.

An expected consequence is a burdensome
workload upon our medical team. While the ma-
jority of Mississippians receive excellent care,
many do not. We must in all candor and honesty
recognize that there are large groups in our state
who receive little or no medical care. It is not suf-
ficient for us to proclaim that we never turn a pa-
tient away or to say that we will care for anyone
who comes to us.

Many of our Mississippi citizens who receive
little or no care are so deprived economically as
to be unable to seek medical services. Now, it is
important to recognize also that neither the prob-
lem nor the solution is the total responsibility of
the medical profession, but we have leadership
responsibilities in seeking solutions which are in-
escapable.

We need new and innovating methods of tak-
ing medical care to the poor within the best
framework available, our private care delivery
system. We must assist and lead in developing a
strong, positive outreach to those who are remote
emotionally, educationally, intellectually, and ec-
onomically.

INEVITABLE COURSE

We must do this because it is the good and
proper course. But it has also become abundantly
clear that if we do not do it, then it will be done
by others under circumstances not of our making
or desire. If we are unable to lead in bringing
good and sufficient medical care to all of our citi-
zens, then we should lose the leadership posture
we occupy for we would not have measured up to
the task.

The outreach to the poor, the deprived, and
the remote is particularly needed in the rural
areas of our state, and the growing core of our
cities should not escape attention. I call on medi-
cal organization to rise to this serious and de-
manding challenge. Some mechanisms for extend-
ing care already exist: Medicaid which sorely
needs our help to succeed from its late and shaky
beginning, our system of public health depart-
ments and public welfare agencies which can as-
sist in case finding and care organization, and
specialized agencies of state government with
unique abilities to coordinate and furnish infor-
mation.

In the midst of this massive effort, medicine
must also look within as well as outside. We must
be the masters of our own house. The vast ma-

jority of Mississippi physicians, as is true of all
American physicians, are competent, honorable
individuals. But there are a few self-serving phy-
sicians who bring discredit upon us all. They are
the underscored examples of ills, evils and abuses
heaped upon us by free-swinging mass media,
those who seek any means of social change, and
those who decry and destroy but who offer no so-
lutions.

PEER REVIEW PROGRAM

Within our own ranks, we must develop a
working system of peer review as an effective in-
strument for self-regulation. The unacceptable al-
ternative— and it is virtually upon us — is submis-
sion to third parties who would sit in judgment
upon the quality of care and the price paid for it.

Physicians are best equipped to make these
judgments, but we must make responsible and
worthy judgments if we are to have them ac-
cepted.

Your Board of Trustees has already initiated a
peer review program, and we must support this
useful beginning with our time, knowledge, and
substance. We must now extend this service to
the component society and medical community
levels, not merely in name but absolutely in fact.
Peer review committees should gather together
the functions of care quality review, fee review,
and grievance committee activities under a single
banner. It should become the point of reference
and the point of appeal.

The work of peer review should include but
not be limited to resolution of differences be-
tween patient and physician, review of the quality
of medical care, adequacy and or reasonableness
of fees, whether due or paid from private or pub-
lic sources, utilization of health care resources,
and liaison with private and public sources of
medical care financing.

EDUCATIONAL ASPECTS

Perhaps most important of all is the thrust of
peer review which is not punitive but educational
and corrective. We must learn to work in harmo-
ny with peer review and honor the judgments of
our colleagues. Otherwise, we shall certainly be
judged by others.

Still other serious and threatening challenges
come from within our state. During the past 10
months, the Legislature has been in session on
two occasions. The 1969 Extraordinary Session
was called to consider Medicaid, and the first of
the annual Regular Sessions was conducted this
year.

Medicaid was enacted at the last minute for its

JULY 1970

375

PRESIDENT’S ADDRESS / Royals

implementation in Mississippi. It is a minimum
program with massive problems, one which ur-
gently requires the support and understanding of
all to succeed. During the special session, there
was clear and unmistakable unrest among legisla-
tors and frequent sharp differences of philosophy
and viewpoint with the health care team.

In the Regular Session, dozens of bills related
to medical care and practice were introduced.
We literally moved from one legislative crisis to
another, losing some, winning some, and prevail-
ing on occasion by the thread-like margin of a
single vote. While the scoreboard shows that we
came out well on bills we supported and those we
opposed, our position was extremely tenuous at
all times. In all frankness, we experienced hostili-
ty toward medicine, and we know that our com-
munications must be improved.

We must communicate with the physician in
his hometown, and he must communicate with
his representative and senator. We must be in-
formed on the issues, and daily dialogue with
the legislator is indispensable. We need reasoned,
positive programs to offer, not just stonewall op-
position. I have learned by unforgettable experi-
ence that it is not enough to write your legislator
a letter or talk to him on one or two occasions.
Constant, continuing contact is essential, and the
legislator must learn that you have a vital interest
in the issues, his position, and his vote.

LEGISLATIVE PROGRAM

We must beef up our legislative effort and pro-
gram, provide more staff' support, and be willing
to give more time personally in this activity.

As I look critically at the manner in which I
practice and observe my colleagues, I arrive at
the inescapable conclusion that we could practice
more efficiently. It may also be fairly noted that
there are inefficiencies in our free enterprise sys-
tem, although it has our support and dedication.
Prepaid group practice, more popularly known as
closed panel medicine, such as Kaiser-Permanen-
te, offers the advantage of efficiency. We need to
adopt measures for efficiency in our private de-
livery system to be more effective and to contain
or even reduce health care costs.

For every inefficiency in our private delivery
system, cost is added, and the cost of illness is
rapidly becoming unacceptable to the American
public. We as physicians must exert every effort
> bring under reasonable control the spiraling
costs of care.

What every Mississippian must understand is
that the circumstances under which medical care
is rendered are not necessarily those of medi-
cine’s choosing or devising. The care climate is
the product of the total social, political, cultural,
and economic environment. No thinking person
would say that hospitals, the worst offenders in
mounting health care price spiral, have deliber-
ately inflicted upon themselves these horrendous
cost problems. Physicians clamoring for associ-
ates in demanding practices have not willed a
shortage of medical manpower.

The simple truth of the matter is that virtually
every system of service, almost every good that is
purchased, and every law that is truly obeyed
are what society wants them to be. To those who
choose to ignore this basic axiom of human na-
ture and charge that American medicine would
turn back the clock, we reply that a science which
has moved itself a century ahead in the span of a
generation is much more the victim than it is the
architect.

LEADERSHIP ROLE

We cannot alone stand accountable for infant
mortality in the city ghetto with slums, lack of
sanitation, and inattention to personal hygiene.
But we can and must assume a leadership role in
the circumstances of care delivery, in taking it in-
to areas of deficit, and in organizing care for ac-
cessibility and availability.

Our delivery system is pluralistic, not mono-
lithic. We have been consistent in opposing — in
the interests of all — the monolith, be it one of
government, of institutions, or a specific ideal or
force of society. We should therefore be willing to
experiment and to innovate, because the give-
and-take of pluralism is a far better state than
the ultimate inflexibility, circumscribed choice,
and single-system domination of the monolith.
We can infuse the flexibility we seek better than
any other source, because we carry the responsi-
bility for rendering medical care.

MEDICAL ORGANIZATION

We are organized together to seek and achieve
these worthy goals, to assume these tasks of lead-
ership, and to meet our responsibilities. It is the
obligation of every physician to work with his col-
leagues toward these ends, to contribute his share,
to give his best thinking, and to make up his part
of the whole.

The most tragic hour in American medicine
comes when a physician withdraws himself in
spirit and substance from medical organization.

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JOURNAL MSMA

He renders himself impotent and he chips a stone
from our foundation. The whole is never greater
than the sum of its parts, and no man is an island.
His dissent should not be translated into destruc-
tion of his organization, of his colleagues, or of
himself. He simply does not have that right.

Medical organization, from the component so-
ciety through the state association of AMA, is re-
sponsive, democratic, and flexible. We must all

work together or fail in the responsibilities we
have assumed.

The delivery system is on trial. Our circum-
stances are neither easy nor simple. But the chal-
lenges are great, and the gauntlet is down. Let us
do what we must to insure the best medical care
for all Mississippians and for all Americans. ***

918 North State St. (39201)

GREATER LOVE HATH NO MAN

The career girl had worked hard and saved her money for a
much-desired cruise vacation. Her diary records the events:

July 5: Ship departed San Francisco for the South Seas. Away
at last. Captain of ship is a very handsome and dashing man.

July 6: Captain invited me to dinner at his table. Delightful.

July 7: Captain invited me to visit bridge and then to his
quarters. He is a most ardent and passionate man. Says if I do
not accept his advances he will blow up ship with 650 passengers
and crew.

July 8: I have just saved 650 lives.

JULY 1970

377

Constitution and By-Laws of the
Mississippi State Medical Association

CONSTITUTION

Preamble

That more may live longer in the richness and com-
fort of health; that pain, suffering, and disease may be
eradicated to the extent made possible by scientific
medical knowledge; that the standards of the medical
profession may be maintained on the highest plane of
honor, we dedicate ourselves as physicians through this
Association. Among us, membership is a privilege,
earned by professional qualification, personal honor, and
selfless service; it is not a right vested superficially nor
by statutory licensure. Truth shall be our quest; diligence,
our staff; and service, our purpose.

Article I

NAME OF THE ASSOCIATION

The name and title of this Association shall be the
Mississippi State Medical Association.

Article II

PURPOSE OF ORGANIZATION

The purpose of this Association shall be to federate
and bring into one compact organization the entire
medical profession of the State of Mississippi and to
unite with similar associations in other states to form
the American Medical Association, with a view toward
the extension of medical knowledge, and to the advance-
ment of medical science; to the elevation of the standard
of medical education, and to the enactment and en-
forcement of just medical laws, to the promotion of
friendly intercourse among the physicians and to guard-
ing and fostering of their opinion in regard to the great
problems of medicine, so that the profession shall be-
come more honorable and capable within itself, and
more useful to the public in the prevention and care of
disease, and in the prolonging of and adding comfort
to life.

The purpose of this Association shall be to promote
scientific medical research and practice and it shall be a
non-profit organization.

Article III

COMPONENT SOCIETIES

Component Societies shall consist of those societies
which hold charters from the Association.

Article IV
MEMBERSHIP

Section 1. Members of the Mississippi State Medical
Association. Members shall be active, associate, or emer-
itus, acording to requirements and provisions of the By-
Laws. There may also be invited guests. Membership
other than associate shall be construed as active in
connection with the rights and privileges accruing there-
from.

Section 2. Guests. Any physician not a resident of
the state may become a guest during any annual session
upon invitation of a member of the Association, and
s all be accorded the privilege of participating in all
the scientific work of that session.

Article V

SESSIONS AND MEETINGS

Section 1. The Association shall hold an annual ses-
sion during which there shall be held daily not less
than two general meetings, which shall be open to all
registered members and guests.

Section 2. The time and place for holding the annual
session shall be fixed by the House of Delegates, but
in emergencies, the Board of Trustees shall have the
power to fix, or change, either the time or the place,
or both of the annual session.

Article VI

GENERAL OFFICERS

Section 1. The general officers of this Association
shall be a President, President-elect, three Vice-Presi-
dents, one from each Supreme Court District, Secretary-
Treasurer, Speaker, Vice Speaker, and Editor.

Section 2. The President, President-elect, and Vice-
Presidents shall hold terms of one year. The Secretary-
Treasurer, Speaker, Vice Speaker and Editor shall be
elected for terms of three years.

Section 3. The officers of this Association shall be
elected by the House of Delegates on the last day of
the annual session following the adjournment of the
general meeting, but no person shall be elected to any
such office who has failed to attend two-thirds of the
past two and current annual sessions and who has not
been a member for the past two years.

Section 4. In addition to these general officers, there
shall be an Executive Secretary who need not be a
physician or member of the Association. He shall be
appointed by the Board of Trustees and shall serve at
the pleasure of the Association. His compensation and
expenses for duties performed shall be fixed by the
Board of Trustees and confirmed by the House of Del-
egates.

Article VII

EXECUTIVE OR CENTRAL OFFICES

The Executive Secretary shall maintain in the city
of Jackson suitable offices for the discharge of his duties
and for conducting the administrative affairs of the Asso-
ciation.

Article VIII

HOUSE OF DELEGATES

The House of Delegates shall be the legislative, busi-
ness, and policy-making body of the Association and
shall consist of (1) delegates selected by the component
societies under authorized apportionment, (2) the gen-
eral officers of the Association, (3) all past presidents,
provided they still be members in good standing of the
Association, (4) members of the Board of Trustees and
Councils, and (5) elected committees. Delegates and
Alternate Delegates to the American Medical Associa-
tion, members of the State Board of Health, and mem-
bers of the Board of Trustees of Mental Institutions, all
of whom must be members of this Association.

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JOURNAL MSMA

Article IX
BOARD OF TRUSTEES

The Board of Trustees shall be the executive and
governing body of the Association during vacation of
the House of Delegates and shall perform such duties as
are prescribed by law governing directors of corpora-
tions and in the By-Laws of the Association. The Board
shall consist of nine members, one from each Associa-
tion District, elected for terms of three years each. A
Trustee shall not serve more than three consecutive
terms.

Article X

FUNDS AND EXPENSES

Funds for meeting the expenses of the Association
shall be arranged for by the House of Delegates by
annual dues, per capita assessments upon the member-
ship, and by voluntary contributions. Funds may be
appropriated by the House of Delegates to defray the
expenses of the annual session, publications, and for
any other purpose approved by the House of Delegates.

Article XI
THE SEAL

The Association shall have a common Seal with power
to break, change or renew the same at pleasure.

Article XII

AMENDMENTS

The House of Delegates may amend any article of
this Constitution by a two-thirds vote of the delegates
registered at the annual session, provided that such
amendment shall have been presented in open meeting
at the previous annual session, and that it shall have
been sent officially to each component society at least
two months before the session at which final action is
taken.

BY-LAWS

Chapter I
MEMBERSHIP

Section 1. Eligibility. Each component society of the
Mississippi State Medical Association shall judge the
qualifications of candidates for election to membership
therein, which shall be restricted to those persons who
hold the degree of Doctor of Medicine from an appro-
priately accredited source as defined by the American
Medical Association, or in lieu thereof, a foreign degree
in medicine which is an acceptable equivalent to the
Board of Trustees and shall be a citizen of the United
States. All candidates for any degree of membership
other than associate must be legally licensed to practice
medicine in Mississippi. Persons who obtained this
degree prior to January 1, 1917, need not comply with
this requirement but must be licensed to practice med-
icine in Mississippi or, if offering to practice in Missis-
sippi must be eligible for license by reciprocity and be
a member in good standing of a constituent (state) asso-
ciation of the American Medical Association. Member-
ship in a component society, evidenced by the payment
of dues for the current year, shall be a prerequisite to
membership in the Association, except that a physician
upon his initial application for membership in a com-
ponent society of the Association shall be required to
undergo a waiting period of ninety (90) consecutive
days from the date he begins the practice of medicine
in the geographical area of the component society be-
fore he may be elected to membership in the component
society. No physician shall be eligible for membership

who has been convicted of or who has plead guilty
to either a felony or a violation of a state or federal
narcotics law. The duly certified court record shall be
prima facie evidence of pleas and convictions and cause
automatic revocation of membership. No physician shall
be eligible for election to or continuation of membership
who does not possess a currently effective federal nar-
cotics stamp, provided, however, that physicians in full
time government service who need no registration to
use, prescribe, and dispense narcotic drugs and those
who, by reason of type of practice, employment, inac-
tivity, or retirement, neither prescribe nor dispense nar-
cotics and who for this reason alone have not applied
for registration shall be exempt from this requirement.

Section 2 (a). Good Standing. Only those members
in good standing shall be entitled to the rights and
privileges of membership. A physician not in good
standing may not be elected to office nor exercise the
privilege of voting or attending any session of this
Association, scientific or otherwise. The name of a
physician upon the properly certified roster of a com-
ponent society which has paid its annual assessment
shall be prima facie evidence of his right to register at
the annual session of the Mississippi State Medical
Association. No member shall participate in any of
the proceedings of the annual session until he is duly
registered. No delegate or other member shall take part
in any of the proceedings of an annual session until he
has complied with the provisions of this section, (b)
Change of State Residence. In the event that a member
moves from the State, his membership shall continue
until, and lapse at the end of, the current fiscal year,
but this provision shall not operate to prevent a physi-
cian who moves from the state continuing his member-
ship by payment of all dues and assessments to the
state Association, (c) Obligations of Membership. When
the Executive Secretary of the Mississippi State Medical
Association is officially informed by the secretary of a
component society that a physician is not in good stand-
ing in the component society, he shall remove the name
of the physician from the rolls of the Association. A
member shall hold his membership through the compo-
nent society in the jurisdiction of which he practices,
provided that a physician living on or near a county
line may hold membership in the society most conven-
ient for him to attend. If the society in which he chooses
to secure membership does not exercise jurisdiction over
the area of his residence, then permission must be ob-
tained from the jurisdiction society to facilitate his affili-
ation with the extra-jurisdiction society.

Section 3. Degrees of Membership. Members of the
Mississippi State Medical Association shall be divided
into the following classifications: Active, emeritus, and
associate, (a) Active Membership. Active members shall
include all eligible members of component societies in
good standing, providing that all dues and assessments
in this Association as may be hereinafter prescribed have
been received by the Association, (b) Emeritus Mem-
bers. Any members of the Mississippi State Medical As-
sociation who has been an active member for any ten
consecutive years and shall have permanently retired
from the practice of medicine shall be eligible for elec-
tion to emeritus membership. Election to emeritus mem-
bership for reason of retirement in the case of permanent
and total disability shall merit special consideration but
shall be subject to ruling by the Board of Trustees. Elec-
tion to emeritus membership shall be based on the rec-
ommendation of the component society and the ap-
proval of the Board of Trustees, (c) Associate Mem-
bership. Any commissioned medical officer in the United
States Army, United States Air Force, United States
Navy, or United States Public Health Service, or any
physician in the employ of the Veterans Administra-
tion, not licensed to practice in the State of Missis-
sippi, stationed in Mississippi, members of medical
faculties of medical schools in Mississippi, approved by

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379

h'bAL f H

the American Medical Association, who are not licensed
to practice in the state, any hospital intern, or any hos-
pital resident in Mississippi, may, on election to associate
membership by the component society in whose juris-
diction the physician resides become an associate of
the Mississippi State Medical Association. Associate
members shall not vote or hold office.

Section 4. Dues and Assessments. A per capita assess-
ment determined by the House of Delegates shall con-
stitute the dues of the Association, which assessment
shall be collected from all active members by the re-
spective secretaries of the component societies, provided
that new members shall be accepted on payment of
three-fourths of annual dues after May 1 and one-half
of annual dues after September 1. Each active member
shall pay the prescribed dues to the officer designated by
the component society for transmittal to the Executive
Secretary of the Association. Dues shall include a sub-
scription to the official publication of the Association,

(a) Members Excused From Payment. The Board of
Trustees may, by majority vote, excuse a member from
payment of dues because of undue hardship or similar
circumstances warranting special consideration provided
that the component society shall have excused in full
the payment of dues for periods exceeding one year. Such
circumstances shall be interpreted to include extended
illness and temporary disability. Members who shall have
attained age 70 and who have been active members of
the Association for any 10 consecutive years may, upon
request, be exempt from dues for life effective January 1
after the 70th birthday, and such exemption shall con-
tinue so long as the member continues in good standing
in his component medical society, (b) Emeritus Mem-
bers. Physicians who have been elected emeritus members
shall not be required to pay dues in the Association,
(c) Payment of Dues and Delinquency. Dues of the
Association are due and payable on December 31 of
the year prior to that for which dues are prescribed.
Failure to pay dues by April 1 of the year for which due
shall result in forfeiture of membership privileges and
the removal of the member’s name from the rolls of the
Association. A five dollar ($5.00) reinstatement cost
shall be assessed against any member who is delinquent
by reason of non-payment of dues after April 1 of the
year for which dues are payable. A member in good
standing who is called to active duty with the Armed
Forces of the United States other than in the regular
component shall be carried as an active member without
payment of dues until such time as he is released from
military service.

Section 5. American Medical Association. Members
of this Association shall pay the dues or hold a legal
exemption from the dues of the American Medical As-
sociation. These dues shall be paid through the com-
ponent society to the Executive Secretary of the Missis-
sippi State Medical Association, whose duty it shall be
to transmit them to the American Medical Association
and to obtain proper credits and receipts therefor.

Section 6. Revocation of Emeritus or Associate Mem-
bership. Any emeritus or associate membership may be
revoked by two-thirds vote of the House of Delegates
when, in the opinion of the House of Delegates, the
conduct or actions of the emeritus or associate member
violates any of the principles of the code of ethics or
whose conduct or actions are not becoming to the honor
conferred.

Chapter II

ANNUAL AND SPECIAL SESSIONS

Section 1. Time and Place. An annual session shall
be held as required by Article V, Section 1, the Con-
stitution of the Mississippi State Medical Association,
which session shall in any event be held prior to the
annual session of the American Medical Association.
The place of the state session shall be fixed in accord-
ant with Article V, Section 2, the Constitution of the
Mississippi State Medical Association.

Section 2. Special Session. A special session of
the Association or of the House of Delegates may be f
called by the President, with the approval of the
Board of Trustees. The Board of Trustees is empow-
ered to call a special session Dy majority concurrence.

Section 3. Inviting an Annual Session. A component
society desiring the Association and House of Delegates
to meet in annual session in a city within its jurisdiction
may submit an invitation in writing or verbally through
its representative to the House of Delegates at the an-
nual session concerned with the selection of the site for
the next regular scheduled meeting. The dates and site
of the annual session selected may be changed by ma-
jority vote of the Board of Trustees in an emergency
requiring such a change.

Section 4. Registration Privileges. Only the following
shall be permitted to register at any session:

(a) Active members

(b) Emeritus members

(c) Associate members

(d) Invited guests

(e) Medical students of American Medical Associa-
tion approved medical schools who are certified
to the Executive Secretary of the Association by
their respective deans.

(f) Interns and residents who are graduates of Amer-
ican Medical Association approved medical
schools and who are connected with an approved
hospital and who are certified to the Executive
Secretary of the Association by their respective
hospital superintendents in event they are not as-
sociate members of the Association.

(g) Commissioned medical officers of the United
States Armed Forces who are on active duty and
who if not associate members are certified to the
Executive Secretary by their Post or Base Sur-
geons or Commanding Officers.

Section 5. Indebtedness. A member shall not be per-
mitted to register unless all current indebtedness to both
the Association and component of proper jurisdiction has
been paid.

Section 6. Admittance. Admittance to any meeting of
the House of Delegates, any scientific section, or any
of the various exhibits at an annual session of the As-
sociation shall be limited to members in good standing,
duly registered and invited guests, members in good
standing of the Woman’s Auxiliary to the Mississippi
State Medical Association, duly accredited and regis-
tered members of the Press, and accredited technical
and scientific exhibitors.

Chapter III
GENERAL MEETING

Section 1. Participation. The general meeting shall
include all registered members and guests, who shall
have equal rights to participate in the proceedings and
discussions, but no member shall vote on any question
coming before a section of the general meeting except
those who have registered as members of such sections.
Each section of the general meeting shall be presided
over by its chairman. The address of the President and
the Distinguished Service Oration shall be delivered be-
fore the general meeting at such time and place as may
be arranged.

Section 2. Order. The order of exercise, papers, and
discussions as set forth in the official program shall be
followed from day to day until it has been completed.
But no section shall be allowed to place more than five
papers on its program, nor more than two invited guest
essayists (out-of-state or non-member). When a section
program is not completed within the time assigned, it
shall not be allowed to continue into that assigned to
another section.

Section 3. Time Restrictions. No address or paper
before the Association, except those of the President
and Orator, shall occupy more than twenty minutes in
its delivery, except that guests may be allowed thirty

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minutes; and in formal discussion no one shall speak
more than five minutes; and in informal discussion no
one shall speak more than three minutes and not more
than one time.

Section 4. Essayists. With the exception of the invited
guests, the essayists must be members of the Association.
No name shall appear more than once on the printed
program to discuss a paper before the regular scientific
sections unless such person qualifies for membership as
provided in these By-Laws.

Section 5. Papers. All papers read before the Associa-
tion shall be its property. Each paper must be read by
its author, and must be deposited with the Secretary
when read.

Section 6. Failure to Read Paper. No author listed on
the program who fails to read a paper at the session
may be allowed a place on the program of the next an-
nual session, but if the author, being unable to attend,
shows his good intent by forwarding his paper to the
Secretary before the annual session, he shall not suffer
the penalty.

Chapter IV
SCIENTIFIC SECTIONS

Section 1. Designation of Sections. The scientific sec-
tions of the Association shall be as follows: (a) Section
on Medicine, (b) Section on Surgery, (c) Section on
Preventive Medicine, (d) Section on Eye, Ear, Nose and
Throat, (e) Section on Pediatrics, (f) Section on Ob-
stetrics and Gynecology, and (g) Section on General
Practice.

Section 2. Section Officers. Each scientific section of
the Association shall, as the last order of business
during its regular meeting, elect a chairman who shall
serve for a period of one year. A majority of votes cast
shall be necessary to elect. Additionally, each section
shall elect a secretary whose term of office shall be for a
period of three years and so arranged that secretaries
shall be elected by their respective sections at the same
annual meeting as follows: (1) Sections on General
Practice and EENT, (2) Sections on Obstetrics and
Gynecology and Preventive Medicine, and (3) Sections
on Pediatrics, Surgery, and Medicine.

Section 3. Program. The Council on Scientific As-
sembly shall place any paper in its proper section. The
Council shall so arrange the program that no one sec-
tion shall be given precedence over others two years in
succession.

Chapter V
HOUSE OF DELEGATES

Section 1. Apportionment and Representation. Each
organized county shall be entitled to representation in all
regular and special sessions of the House of Delegates,
one delegate and one alternate for each fifty members in
the county and one delegate and one alternate for each
fraction thereof, but each organized county holding a
charter from this organization having made its annual
report and paid its assessments, as provided in this Con-
stitution and By-Laws shall be entitled to at least one
delegate and alternate, said alternate delegates to act only
in the absence of the delegate or delegates from the
respective counties. No county in a component society
shall be without representation in the House of Dele-
gates; each shall be entitled to one delegate and one
alternate without regard to total membership. No alter-
nate may be seated at any regular or special session of
the House of Delegates unless the delegates elected from
that county shall be absent or otherwise unable to par-
ticipate in the proceedings. In the event that neither the
delegate nor the alternate is able to attend the regular or
special session to which they have been accredited, then
any bona fide resident of the county may, if properly
registered, qualify himself as a delegate. No representa-
tive of the component society shall be seated in the
House of Delegates until all his dues, assessments, and

obligations to the component society have been paid.
Delegates and alternates shall be elected by their re-
spective component societies for terms of not less than
two years and shall assume office on the first day of the
annual session following their elections; they shall be
bona fide residents of the counties which they represent.
Their names shall be reported to the Central Office of
the Association not later than thirty days prior to the
first day of the annual session. Representatives of com-
ponent societies shall be seated in the House of Delegates
only following their proper registration of credentials
from the component societies they represent.

Section 2. Meetings and Attendance. The House of
Delegates shall meet annually on the first day of the
annual session of the Association. The House of Dele-
gates shall meet for the conclusion of business on the
last day of the annual session immediately following
the adjournment of the last general or scientific ses-
sion, provided that these requirements shall not op-
erate to prevent such other meetings of the House of
Delegates during the annual session as the House itself
may order or the President or Speaker may deem nec-
essary, but no such meetings may be called at times
which would conflict with the scheduled general or
scientific session. Duly registered members and guests
may attend all meetings of the House of Delegates pro-
vided that they occupy a distinctly separate section of
the meeting hall or auditorium and further provided that
they shall not be permitted to participate in any phase
of the meeting of the House of Delegates except on in-
vitation of that body. By majority vote, the House of
Delegates may enter into executive session, during which
time only qualified delegates and officers of the Associa-
tion may remain in attendance.

Section 3. Quorum. A three-fifths majority of regis-
tered and duly seated delegates of this Association shall
constitute a quorum.

Section 4. Order of Business. The order of business
shall be conducted at the pleasure of the House of Dele-
gates, provided it shall not be in conflict with either these
By-Laws or the Constitution. Meetings shall be conducted
according to Robert’s Rules of Order, Revised, and with-
in the bounds of courtesy and this Constitution and By-
Laws. Generally, the order of business shall be:

(1) Adoption of the Transactions of the previous
meeting.

(2) Reports of Boards, Councils and Committees.

(3) Reports of Presidential Committees.

(4) Special Orders.

(5) Unfinished Business.

(6) New Business.

Section 5. Memorials and Resolutions. No memorials
or resolutions shall at any time be issued in the name of
the Mississippi State Medical Association by any officer
or member thereof until such memorial or resolution has
been approved and adopted by the House of Delegates
or Board of Trustees.

Section 6. Duties and Responsibilities. It shall, through
its officers and otherwise, give diligent attention to foster
the scientific work and spirit of the Association, and
shall constantly study and strive to make each annual
session a stepping stone to future ones of higher in-
terest. It shall consider and advise the public in those
important matters wherein it is dependent upon the pro-
fession, and shall use its influence to secure and enforce
all proper medical and public health legislation and to
diffuse popular information in relation thereto. It shall
make careful inquiry into the condition of the profession
of each county in the state, and shall have authority to
adopt such methods as may be deemed most efficient for
building up and increasing the interest in such county
societies as already exist, and for organizing the profes-
sion in the counties where societies do not exist. It shall
especially and systematically endeavor to promote
friendly intercourse between physicians of the same
locality, and shall continue these efforts until every
physician in every county in the state has been brought

JULY 1970

381

under medical society influence. It shall encourage post-
graduate work in medical centers, as well as home study
and research, and shall endeavor to have the results
utilized and intelligently discussed in the component
societies. It shall elect representatives to the House of
Delegates of the American Medical Association in ac-
cordance with the Constitution and By-Laws of that
body, the term of office to begin on January 1 of the
year following that of the elections and continuing for
two successive years. It shall, upon recommendation of
the Board of Trustees, provide and issue charters to
counties organized to conform to the spirit of the Con-
stitution and By-Laws.

Section 7. Reference Committees. Business brought
before the House of Delegates will normally be referred
by the Speaker for hearing, debate, and recommenda-
tion to a reference committee. Sufficient reference com-
mittees shall be appointed by the President to expedite
and assist in the deliberations of the House of Delegates.
Such committees shall consist of not less than three nor
more than five members, all of whom shall be members
of the House of Delegates, who shall serve only during
the regular or special session for which appointed. Any
member of the Association shall have the privilege of
appearing before a reference committee on any issue
being considered. Additionally, reference committees may
permit the appearance of any individual who, in the
opinion of the committee, can assist its deliberations.

Chapter VI

ELECTION OF OFFICERS

Section 1. Ballot. All elections shall be by secret
ballot, and a majority of the votes cast shall be necessary
to elect.

Section 2. Nominations. The House of Delegates on
the first day of the annual session shall select a Com-
mittee on Nominations consisting of nine members of
the House of Delegates, one from each Association
District. It shall be the duty of this committee to consult
with the members of the Association and to hold one or
more meetings at which the best interests of the Associa-
tion and of the profession of the state for the ensuing
year shall be carefully considered. The committee shall
nominate to the House of Delegates three names for each
general officer vacancy and two names for all other
offices. No two candidates for President-elect may be
named from the same county. Nominations for appoint-
ment to membership on the Missouri State Board of
Health shall be made by the House of Delegates in ac-
cordance with Section 7024, Mississippi Code of 1942,
provided that six names shall be submitted, three of
whom shall be elected and their names submitted to the
Governor as nominees from each district, provided no
member shall be nominated who has served two con-
secutive terms. The House of Delegates shall nominate
five physicians when vacancies occur on the Board of
Trustees of Mental Institutions which nominations shall
be submitted to the Governor in accordance with law.

Section 3. Report of Nominations. The House of
Delegates shall receive the report of the Committee on
Nominations and elect officers, Trustees, and Council
members on the last day of the annual session.

Section 4. Nominations from the Floor. Nothing in
this Chapter shall be construed to prevent additional
nominations being made from the floor by members of
the House of Delegates.

Section 5. Executive Secretary. The Board of Trustees
hall select and appoint an Executive Secretary as else-
where prescribed in the Constitution and By-Laws of the

Association.

Chapter VII
DUTIES OF OFFICERS

Section 1. President. The President shall have general
supervision over all meetings of the various bodies of
the Association, shall appoint all committees not other-
wise provided for, shall deliver an annual address at such
time and place as may be arranged, and shall perform
such other duties as custom and parliamentary usage
may require. He shall fill by appointment all vacancies
occurring during his tenure of office among the general
officers and on the Board of Trustees and Councils and
shall be empowered to appoint such committees on an
ad hoc basis as may be desired or required to conduct the
affairs of the Association. He shall be an ex officio mem-
ber of all Councils and committees. He shall be the real
and acknowledged head, as well as the personal represent-
ative, of the medical profession of the State of Missis-
sippi during his term of office, and insofar as practicable,
shall visit by appointment the various sections of the
state and the component societies of the Mississippi State
Medical Association and assist the Trustees in their tasks
of aiding and strengthening the component societies and
in making their work more useful.

Section 2. President-elect. The President-elect shall be
in charge of the work of organization, including member-
ship, under the direction of the President, and shall ex-
ercise these duties and advise with the Vice Presidents
and with the Board of Trustees in this phase of their
activity. He shall be an ex-officio member of all Councils
and committees. He shall succeed to the presidency upon
the event of the death, resignation, or removal from
office of the President. This automatic succession shall
not operate to disqualify him from serving the next
regular term of office unless he has served more than
six months as President.

Section 3. Vice Presidents. The Vice Presidents shall
assist the President in the discharge of his duties. They
shall further assist the President-elect in the work of
organization, including membership in their respective
areas, and in promoting the welfare of the Association
and the profession of the state.

Section 4. Speaker. A Speaker shall be elected for
a term of three years. This officer may be chosen from
the membership of the Association, irrespective of any
affiliation with the House. The Speaker shall familiarize
himself with the rules and usages of parliamentary pro-
cedure, with the laws of the House. On him shall devolve
the duty of bringing before the House through the var-
ious officers and chairmen all reports and other matters
that are to receive its attention. He shall preside at all
meetings of the House and perform the duties usual to
the position and office of chairman except in the ap-
pointment of committees, which shall be the privilege of
the President.

Section 5. Vice Speaker. A Vice Speaker shall be
elected for a term of three years to run concurrently
with that of the Speaker. The Vice Speaker shall assist
the Speaker in all duties prescribed in these By-Laws.

Section 6. Secretary-Treasurer. The Secretary-Treas-
urer shall be elected for a term of three years. He shall
perform such duties ordinarily devolving on a secretary
of a corporation by law, custom, or parliamentary usage
and shall enjoy the rights and perform such other duties
as may be granted or imposed in the Constitution and
these By-Laws. He may delegate such duties as are
herein described to the Executive Secretary who shall be
responsible therefor. He shall be an ex-officio member of
all Councils and committees.

Section 7. Executive Secretary. The Executive Secretary
shall be appointed by the Board of Trustees and shall
serve at the pleasure of the Association. He need not be
a member of the Association nor a physician. He shall
maintain a Central Office for the Association and shall be
responsible for the management and proper functioning
of the Central Office to the President of the Association
and the Board of Trustees. He shall attend all sessions

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and meetings of the Association, the House of Delegates,
the Board of Trustees, and shall serve at all times to
perform such other duties as may be deemed beneficial to
the Association by the President and Board of Trustees.
He shall assist elected officers, Councils, committees, and
Trustees in the performance of their duties. Under in-
structions from the President, he shall conduct a com-
prehensive program of public education and all such
other activities as may disclose favorably to the public
at large the aims, objectives, and goals of service of the
medical profession in Mississippi. He shall, when re-
quested, place himself in position to assist any of the
component societies of the Association and he shall
attend meetings of the component societies when invited
by officers thereof. He shall be made custodian of rec-
ords, books and papers belonging to the Association and
he shall keep account of and promptly place under the
supervision of the Secretary-Treasurer such funds as may
be delivered into his hands in the name of the Associa-
tion. He shall give bond at the expense of the Association
in such amount as may be required. He shall provide
for the registration of the members and delegates at the
annual session and cooperate in preparing for and ar-
ranging all functions of the Association, including the
annual session. He shall procure an exact transcript of
all proceedings of the House of Delegates. He shall
maintain a register of all legal practitioners in Mississippi
and he shall maintain detailed and exact records of the
membership with regard to component societies, the
Mississippi State Medical Association, and the American
Medical Association. He shall issue evidence of member-
ship to each physician who pays the annual assessment
and is accepted in the Mississippi State Medical Associa-
tion. He shall maintain close and complete liaison with
the American Medical Association and shall keep the
component societies informed of activities, programs, and
mandates of both the state Association and the Ameri-
can Medical Association. He shall publish from the
Central Office such memoranda, bulletins, and miscel-
laneous publications as may be directed by the President,
the Board of Trustees, and the House of Delegates. He
shall conduct the official correspondence of the Associa-
tion as he may be directed. He shall employ such as-
sistants as may be required, upon authorization of the
Board of Trustees. He shall supply each component
society with blank forms to be used in connection with
membership and reports. He shall maintain records of
monies paid by the component societies for assessments
and dues. He shall prepare and publish under the direc-
tion of the President and Board of Trustees such pro-
grams as may be necessary for official functions of the
Association. He shall be reimbursed for expenses in-
curred in the performance of his duties, separately and
in addition to his regular compensation.

Chapter VIII

BOARD OF TRUSTEES

Section 1. Board of Trustees. The Board of Trustees
shall be the executive and governing body of the As-
sociation during vacation of the House of Delegates. It
shall consist of nine members, one from each Association
District, where terms of office shall be three years and
so arranged that only three members are elected an-
nually. A Trustee shall not serve more than three con-
secutive terms. During vacation, the Board of Trustees
shall exercise the powers conferred upon the House of
Delegates by the Constitution and these By-Laws, pro-
vided that in the exercise of these powers thus conferred,
the Board of Trustees shall neither consider nor act to
contravene any action, mandate, or policy of the House
of Delegates which may still be in effect.

Section 2. Officers of the Board. The Board of Trustees
shall elect from its membership a Chairman, a Vice

Chairman, and a Secretary for terms of one year during
the last day of the annual session following adjourn-
ment of the House of Delegates. These officers of the
Board shall compose its Executive Committee. The duties
of the Secretary may be delegated to the Executive
Secretary who shall maintain such special records and
transcripts of meetings as the Board may desire.

Section 3. Meetings of the Board. The Board of
Trustees shall meet daily during the annual session of
the Association and at such other times as necessity may
require, subject to the call of the Chairman or on petition
of any three members of the Board.

Section 4. Executive Committee. The Executive Com-
mittee of the Board of Trustees shall be empowered to
act in behalf of the Board on all matters delegated to
it by majority vote of the Board. The acts of the Execu-
tive Committee, however, shall be subject to confirma-
tion by the Board.

Section 5. Reports of the Board of Trustees. The
Board of Trustees shall make an annual report to the
House of Delegates and such supplemental reports as
necessity may require at a time designated in the regular
transaction of the business of the House. The report
shall be made by the Chairman, the Vice Chairman, the
Secretary, or the Executive Secretary. The reports of the
Board shall be made a portion of the annual transactions
and proceedings of the Association.

Section 6. Duties of Trustees. Each Trustee shall be
organizer and arbiter for his Association District. He
shall visit the component medical societies within his
District during each year and shall make an annual re-
port of his activities and of the condition of the medical
profession of each county of his District. Each Trustee
shall be reimbursed for expenses incurred by him in
traveling within his District or attending special meet-
ings in the performance of his official duties, which will
be allowed upon presentation of an itemized and docu-
mented account. This provision shall not be construed
to include his expenses in attending the annual session
of the Association.

Section 7. Public Policy. The Board of Trustees shall
have the right to communicate the views of the medical
profession and of the Association in the State of Mis-
sissippi with regard to matters of medical science, health,
sanitation, and allied spheres of activity. It shall ap-
prove all memorials and resolutions issued but shall not
issue memorials and resolutions heretofore prohibited in
these By-Laws.

Section 8. Association Districts. The State of Mis-
sissippi shall be subdivided into Association Districts by
counties, provided that all counties in a component
society shall be in one Association District. These dis-
tricts are defined as follows:

District 1:

District 2:
District 3:

District 4:
District 5:

District 6:
District 7:

District 8:

District 9:

Bolivar, Coahoma, Humphreys, Leflore,
Quitman. Sunflower, Tallahatchie, Tunica,
and Washington.

Benton, DeSoto, Lafayette, Marshall, Pa-
nola, Tate, Tippah, Union, and Yalobusha.
Alcorn, Calhoun, Chickasaw, Clay, Ita-
wamba, Lee, Lowndes, Monroe, Noxubee,
Oktibbeha, Pontotoc, Prentiss, and Tisho-
mingo.

Attala, Carrol, Choctaw, Grenada, Holmes,
Montgomery, and Webster.

Hinds, Issaquena, Leake, Madison, Rankin,
Scott, Sharkey, Simpson, Smith, Warren, and
Yazoo.

Clark, Kemper, Lauderdale, Neshoba, New-
ton, and Winston.

Covington, Forrest, George, Greene, Jasper,
Jefferson Davis, Jones. Lamar, Marion,
Pearl River, Perry, and Wayne.

Adams, Amite, Claiborne, Copiah, Frank-
lin, Jefferson. Lawrence, Lincoln, Pike,
Walthall, and Wilkinson.

Hancock, Harrison, Jackson, and Stone.

JULY 1970

383

Chapter IX
COUNCILS

Section 1. Councils. Councils of the Association shall
be elected standing bodies of the House of Delegates,
responsible thereto. There shall be a Council on Medical
Service, a Council on Scientific Assembly, a Judicial
Council, a Council on Constitution and By-Laws, a
Council on Legislation, a Council on Budget and Fi-
nance, an Editorial Council, and a Council on Medical
Education. A Council member shall not serve more than
three consecutive terms.

Section 2. Council on Medical Service. The Council
on Medical Service shall be charged with the responsi-
bilities of ascertaining and studying all aspects of med-
ical care in Mississippi. It shall examine and make
available all facts, data, and opinion on timely and
adequate medical care. It shall investigate social and
economic aspects of medical care and report its evalua-
tions and findings. It shall suggest means of distribution
of adequate quality medical service to the public con-
sistent with the policies of the Association. It shall act
as a factfinding and advisory body of the Association.
Under its jurisdictions, there shall be assigned the ac-
tivities of the Association in medical service, emergency
service programs, indigent care, and allied medical
agencies. There shall be one member from each Associa-
tion District elected for a term of three years and so
arranged that only three members shall be elected for
full terms each year. The Council on Medical Service
shall appoint Committees on Occupational Health, Ma-
ternal and Child Care, Mental Health, and Blood and
Blood Banking. Each committee shall consist of not less
than five nor more than seven members appointed for
periods of not less than one nor more than three years.

Section 3. Council on Scientific Assembly. The Council
on Scientific Assembly shall be composed of the Secre-
tary-Treasurer and the chairman and secretaries of the
several scientific sections. The Secretary-Treasurer shall
be chairman of the Council. Upon this Council shall
devolve the duties and responsibilities of planning the
annual session to include all scientific activity and the
programming and scheduling of annual session events.
The Council shall be empowered to appoint such com-
mittees for terms not to exceed one year as may be
necessary to assist in the discharge of these duties.

Section 4. Judicial Council. The Judicial Council shall
consist of nine members elected for terms of three years
each, one from each Association District. The judicial
powers of the Association shall be vested in this Council
whose decision shall be final. The Council shall have
jurisdiction in all questions involving membership in the
Association, all controversies arising under the Constitu-
tion and these By-Laws, interpretation and application
of the Principles of Medical Ethics of the American
Medical Association, controversies between two or more
component societies of the Association and among mem-
bers of the Association. The Council shall have appellate
jurisdiction in questions and controversies referred to
the state Association by appropriate and authorized
bodies of component medical societies. Appeals shall
be perfected within six months following the date of
decision by the constituted authority of the component
society. The Council, under these several authorities, may
conduct such hearings as may be necessary and after
due and legal processes may, by majority opinion, cen-
sure, suspend, or expel any member for infraction of
the Constitution or these By-Laws.

Section 5. Council on Constitution and By-Laws. The
Council on Constitution and By-Laws shall consist of
three members elected by the House of Delegates for
terms of three years each. To this Council shall be re-
ferred all suggested amendments and changes in the
Constitution and By-Laws of the Association for recom-

mendation to the Board of Trustees and House of Dele-
gates.

Section 6. Council on Legislation. The Council on
Legislation shall consist of nine members, one from each
association district, elected by the House of Delegates for
terms of three years each which are so arranged that
three members are elected annually. This Council shall
analyze proposed legislation, recommending to the Board
of Trustees courses of action for securing laws in the in-
terests of public health, scientific medicine, as well as
medical practice. It shall study and report the need for
new and remedial legislation designed to serve the best
interests of the state and nation. This Council shall be
responsible to the Board of Trustees.

Section 7. Council on Budget and Finance. The Coun-
cil on Budget and Finance shall consist of five members
elected by the House of Delegates for terms of three
years each which are so arranged that not more than
two members shall be elected annually. This Council
shall receive reports of the finances of the Association
and to it shall be referred all matters pertaining to the
annual budget. The Council shall report annually to the
House of Delegates, making specific recommendations on
the annual budget of the Association. This Council shall
be responsible to the Board of Trustees.

Section 8. Editorial Council. The Editorial Council
shall consist of the Editor and the Associate Editors,
elected by the House of Delegates to serve two years,
and the former shall serve as chairman. To this Council
shall be referred all reports of scientific subjects and
all scientific papers and discussions presented before the
Association and its component societies. The Council
shall consider for publication in the official organ of
the Association such papers, reports, and other data as
may serve to further and advance scientific medicine in
Mississippi. It shall exercise editorial authority over the
official organ of the Association. This Council shall be
responsible to the Board of Trustees.

Section 9. Council on Medical Education. The Coun-
cil on Medical Education shall consist of three mem-
bers elected by the House of Delegates for terms of
three years each. To this Council shall be assigned
the responsibilities of encouraging undergraduate and
postgraduate study of medicine, licensure, and facilities
for medical education in the state. This Council shall
be responsible to the Board of Trustees.

Chapter X

COMMITTEES OF THE
BOARD OF TRUSTEES

Section 1. Committees of the Board of Trustees.
Standing committees of the Board of Trustees shall con-
sist of the Advisory Committee to the Medical Auxiliary,

Peer Review Committee, the Committee on Publications,
and the Committee on Medicine and Religion. All com-
mittees of the Board of Trustees shall be appointed by
the Board for terms specified unless their selection is
otherwise prescribed.

Section 2. Advisory Committee to the Medical Aux-
iliary. The Advisory Committee to the Medical Auxiliary
shall consist of three members appointed for terms of
three years each. The committee shall be charged with
the responsibility of advising the Woman’s Auxiliary to
the Mississippi State Medical Association on matters of
organization and program activity relating to the sup-
portive role of the Auxiliary in its work with the Associa-
tion.

Section 3. Peer Review. The Committee on Peer Re-
view shall consist of nine members, one from each As-
sociation district, appointed for terms of three years each
so as to provide for appointment of three members an-
nually. Members of this committee shall not simultane-
ously serve on any disciplinary body of the Association
or its component medical societies. To this committee
shall be assigned the work of peer review, including but

I lie

I

384

JOURNAL MSMA

It

not limited to resolution of differences between patient
and physician, review of the quality of medical care,
adequacy and/or reasonableness of fees, whether due or
paid from private or public sources, utilization of health
care resources, and liaison with private and public sources
of medical care financing. The committee is empowered
to encourage a response from any member of the As-
sociation in writing or by personal appearance, authority
to initiate investigations on its own motion, and authority
to file charges against a member in the name of the
committee before the Judicial Council or a disciplinary
body of a component medical society. Under no circum-
stances, however, shall the Committee on Peer Review
exercise any disciplinary function nor shall it be em-
powered to alter the status or standing of any member.
The committee shall be empowered to prescribe its rules
of operation which shall not be in conflict with the
policies or By-Laws of the Association. The committee
shall also encourage and assist component medical soci-
eties in forming Committees on Peer Review at the local
level.

Section 4. Committee on Publications. The Commit-
tee on Publications shall consist of six members. These
shall consist of the Editor, the two Associate Editors,
and three others, the three latter being appointed by the
Board of Trustees for terms of three years which are so
arranged to provide for appointment of one such mem-
ber annually. The chairman of the committee shall be
designated by the Board. The committee shall imple-
ment instructions and policies of the Board of Trustees
relating to the official Journal of the Association. Addi-
tionally, the committee shall study and recommend to
the Board policy proposals relating to organization and
production of the Journal, reporting annually its delib-
erations.

Section 5. Committee on Medicine and Religion. The
Committee on Medicine and Religion shall consist of six
members appointed for terms of three years each and so
arranged to provide for appointment of two members
annually. The committee shall be responsible for formu-
lating a program in the field of medicine and religion
and for carrying out such assignments as may be made
in this connection by the Board of Trustees.

Chapter XI
RULES AND CONDUCT

The Principles of Medical Ethics of the American
Medical Association shall govern the conduct of mem-
bers in their relations to each other and to the public.

Chapter XII
COMPONENT SOCIETIES

Section 1. Component Societies. All component so-
cieties now in affiliation with this Association or those
that may hereafter be organized in this state, which have
adopted principles of organization not in conflict with
this Constitution and By-Laws shall, upon application
to the Board of Trustees and approval by the House of
Delegates, receive a charter from and become a com-
ponent part of this Association. The Board of Trustees
and House of Delegates, on recommendation by the
Judicial Council, shall have authority to revoke the
charter of any component society whose actions are in
conflict with the letter and spirit of this Constitution and
By-Laws.

Section 2. Number of Societies. Only one component
medical society shall be chartered in any county but
nothing in this section shall be construed as to prohibit
unofficial organization of medical clubs or other county
level groups of physicians whose purpose it is to further
and advance scientific medicine and postgraduate med-
ical education.

Section 3. Members of Societies. Each component
society shall judge the qualifications of its own mem-
bers, but as such societies are the only portals to
this Association and to the American Medical As-

sociation, every reputable and legally registered phy-
sician who is qualified under Chapter I, Section 1, of
these By-Laws shall be eligible for election to member-
ship. Before a charter is issued to any component socie-
ty, full and ample opportunity shall be given to every
such physician in the county to become a member.

Section 4. Right of Appeal. Any physician who may
feel aggrieved by the action of the society of his county
or District in refusing him membership, or in suspend-
ing or expelling him, shall have the right to appeal to the
Judicial Council, which, upon a majority vote, may per-
mit him to petition for membership in an adjacent
society.

Section 5. Evidence of Appeals. In hearing appeals,
the Judicial Council may admit oral or written evidence,
as in its judgment will best and most fairly present the
facts, but in case of every appeal, efforts at a concilia-
tion and compromise shall precede all such hearings.

Section 6. Area Jurisdiction. A physician living on or
near a county line may hold his membership in that
county most convenient for him to attend, on permission
of the society in whose jurisdiction he resides.

Section 7. Professional Authority. Each component
society shall have general direction of the affairs of the
profession in its jurisdiction and shall constantly use its
influence to the moral and professional betterment of its
physicians, to the end that the membership shall embrace
every qualified physician in its jurisdiction.

Section 8. Meetings. Frequent meetings shall be en-
couraged, and the most attractive programs arranged
that are possible. The younger members shall especially
be encouraged to do postgraduate work, and to give the
society first benefit of such labors. Official positions and
other preferments shall be unstintingly given to such
members.

Section 9. Delegates. Each county shall be entitled to
representation in the House of Delegates of this Associa-
tion, one delegate for each fifty members or fraction
thereof. Delegates shall be elected for terms of not less
than two years and societies shall report such elections
to the Executive Secretary of the Association in no event
later than thirty days before the annual session.

Section 10. Duties of Component Society Secretaries.
The secretary of each component medical society shall
perform such duties as are usual and customary to his
office. He shall maintain the official roll of membership
for his society, shall collect dues and assessments, and
shall make official reports as elsewhere prescribed in
these By-Laws to the Association, transmitting dues in
behalf of component society members He shall conduct
the official correspondence of his component medical so-
ciety.

Chapter XIII
FISCAL YEAR

The fiscal year of the Association and its component
county societies shall begin January 1 each year and
end on December 31 following, but membership in the
state Association shall not lapse until April 1 of that
year.

Chapter XIV
AMENDMENTS

These By-Laws may be amended at any annual session
by a majority vote of the delegates present at that ses-
sion, after the amendment has laid upon the table for
one day.

Chapter XV
REPEALING AUTHORITY

Upon adoption of these By-Laws, all previous By-
Laws, motions of record, mandates, policies, rules and
regulations in conflict therewith are hereby repealed, ex-
cept that officers elected to serve in the Association and
its component societies shall continue their incumbency
until the completion of their previously prescribed terms
and their successors elected under the current By-Laws.

JULY 1970

385

The President Speaking

‘The Making of an M.D.’

PAUL B. BRUMBY, M.D.
Lexington, Mississippi

The summer months are a happy time in many American fami-
lies. This is the season of weddings and graduations. There is a
great thrill in watching little rascals in caps and gowns receiving
diplomas that signify that they are mature enough to begin real
school. The senior recitals and senior parties are all part of our
educational system.

The fascinating thing to me is that somewhere in these years
the heart of a doctor is made. A great many follow in their fa-
ther’s footsteps; others have physicians in their family background; ;
and still others are encouraged by doctors that they know, love
and respect. The picture. The King’s Physician, which hangs in
many physicians’ offices, has caused many serious-minded youths
to think of serving others with untiring devotion.

I believe that we doctors should address ourselves to finding
and encouraging high-type youths to go into the field of medicine.
The lad across the street may have the potential of a great phy-
sician.

We see the statement over and over that those who enter the
field of medicine do so because of renumeration to be gained, i
Nothing could be farther from the truth. No promise of future
compensation could sustain an ambitious youth through the many |
years required before he can sell his services in the health market. (
He sees his fellow graduates who enter other fields forging steadi- I
ly ahead. Among nine physicians who met recently, none thought
that economic factors were even high on the list of future expecta- .
tions of medical graduates. In fact, they felt that somewhere in t
his training, the physician should have access to more knowledge
of the economics of medical practice. a

Any student who has intellectual ability, self-discipline, and un- : ll
flagging ambition will make a success in any endeavor which he [
undertakes. He owes no apology for success. The repeated asser- S
tions seen in the press and heard repeatedly, that the members of > i
our profession are interested solely in pecuniary gain, are infuriat- p
ing. *** i

386

JOURNAL MSM A

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 7

JULY 1970

Medicare’s Part C:
Danger, Dichotomy, Anathema

i

Health care delivery by capitation payment
is the new thrust under Medicare, and if enacted
by the Congress, it could be the pivotal aspect of
the most drastic change yet wrought by a decade
of government in medicine. This is no fantasy,
but it is hard legislation already enacted by the
House of Representatives. It is the little-known
Part C of Medicare, now facing final action in
the Senate.

Part C, in a nutshell, provides for care delivery
by a health maintenance organization, popularly
designated an HMO. This is simply another de-
scription for prepaid group practice care, closed
panel care to most of us; for a medical care foun-
dation; or for a nonprofit or profit corporation.
It departs substantially from the traditional pri-
vate, fee-for-service delivery system, and the
greatest danger implicit in the proposal is its un-
tried, untested, and undocumented status.

Part C entered the Medicare scene abruptly
and reportedly without prior knowledge even of
the government’s number one M.D., Dr. Roger
Egeberg. During final hours of hearings on the
Social Security Amendments of 1970, HEW Un-
dersecretary John G. Veneman made the pro-
posal in executive session before the House Com-
mittee on Ways and Means. It is believed that

JULY 1970

Committee Chairman Wilbur Mills was cool to-
ward it but agreed, in the face of pressure from
his colleagues, to permit experimentation with the
idea.

In any event, the proposal found its way into
the bill which many congressmen voted for with-
out knowing it was there. If anything. Part C
could exert the most profound impact upon medi-
cal practice of any facet of the public financing
mechanism yet enacted.

II

Part C of Medicare has its roots in economy.
This is to say that the government wants the
same and more medical care it now purchases for
less outlay of money. Incredible? Not at all, for
Secretary Robert H. Finch followed up Under-
secretary Veneman by only a couple of days and
said so.

Its provisions make many assumptions, seek
ideals not readily attainable, and asks for more
services for the same or less money. The measure
would permit HEW to make contracts with health
maintenance organizations — HMO’s — and make
per capita payments to them for services to Med-
icare beneficiaries. In lieu of Part A (hospitals,
home health agencies, and extended care facili-
ties) and Part B (payments for physicians’ ser-

3 87

He A t / M

EDITORIALS / Continued

vices and those of allied professionals), the Sec-
retary of HEW would be authorized to determine
a combined Part A and Part B per capita rate for
payment, on a prospective basis, for services pro-
vided by an HMO. Medicare beneficiaries en-
titled to services under Parts A and B could elect
to enroll in an HMO.

The HMO would be required to have at least
half of its members under age 65 and, therefore,
ineligible for Medicare, and it could receive no
more than 95 per cent of amounts otherwise paid
under fee-for-service. For Part B services only,
the HMO could receive “two times the product of
the number of Medicare enrollees and the month-
ly Part B ‘premium’ established by the Secretary.”
This simply means the $10.60 per month, half of
which is paid by (or in behalf of) the beneficiary
and half by the government itself. Part A would
pay the rest.

The HMO may be a public or private organi-
zation, nonprofit or for-profit, which:

— Provides directly or through arrangements
with other health services on a per capita basis.

— Provides Medicare beneficiaries all of the
services and benefits under Parts A and B.

— Provides physicians’ services through em-
ployed physicians, partners, or groups who would
be reimbursed for services on a per capita basis
for enrollees.

— Demonstrates to the satisfaction of the Sec-
retary proof of financial responsibility and capa-
bility to furnish comprehensive health services,
including institutional services — efficiently, effec-
tively, and economically.

— Has enrolled members at least half of whom
are under age 65.

— Assures prompt services with review of qual-
ity standards.

— Opens enrollment at least every two years
and accepts eligible Medicare applicants without
underwriting on a first-come, first-served basis up
to the limit of its capacity, unless such would re-
sult in more than half the enrollees being over
age 65.

Beneficiaries could receive extra emergency
services when unable to go to the HMO. The en-
rollment fee charged the applicant could not ex-
ceed the present cost sharing provisions of Parts
A and B, meaning the $50 deductible and 20
per cent co-pay.

Ill

American medicine had little or no time to re-
act or respond to the Veneman proposal between

its initial presentation in executive session and the
reporting of the bill by the House Committee on
Ways and Means. While sensing the dangers of
the new part, AMA and most state medical asso-
ciations hold to the position that the delivery sys-
tem should be pluralistic, not monolithic. Since
Part A and B are still very much with us, the
new Part C is merely a variation.

But principally, AMA did make a valid point
in stating that full, free choice of physician — and
hence, free choice of financing mechanism, as the
law presently stands — is utterly necessary. AMA
objected to the enactment of Part C without dis-
cussion and testimony, let alone cost and actuarial
data which could have been gleaned from a pilot
program, such as has been underway with the
Health Insurance Plan of New York, the major
eastern closed panel delivery program.

Secretary Finch, speaking in support of Part C,
said that “the federal government is spending
over $10 billion this year to buy health care for
the aged and poor . . . (and) we are not getting
our money’s worth. . . .” This seems to prove a
point which the government has yet to learn:
Costs for any program are eventually three to
five times greater than program proponents say
they will be. Why would Part C be any different

“One of them is my nurse — the rest fill out the
Medicare forms”

388

JOURNAL MSMA

than Part A or Part B when the bills are totaled
up? Moreover, it is highly unlikely that anybody,
the government or whoever, can buy more and
pay less in today’s marketplace.

Then, there is another major impediment to
universal application of Part C, even if passed on
final consideration by the Senate. Twenty-one
states have laws which impair prepaid group
practice or closed panel delivery. Mississippi is
not in this group.

HEW has a blood-chilling answer for this:
Change the state laws, or we will apply “eco-
nomic leverage” with Title XIX and Title V
(maternal and child care) funds. AM A has char-
acterized this action as “unconscionable,” and we
add a hearty amen. To reduce or discontinue
funds for two separate medical programs, enacted
long before Part C became HEW’s bright idea, is
to make a mockery of the initial purpose of the
affected programs. Moreover, such state laws,
which the people had a perfectly legal right to en-
act, were not aimed or directly related toward
any proposal now being considered.

IV

There is a strange dichotomy about Part C
which places some state medical associations be-
tween a rock and a hard place. Less than a dec-
ade ago, a number of medical associations or-
ganized health care foundations to bargain with
state welfare programs for physicians’ services or
at least guarantee equity in assuring medical ser-
vices. California has been a fountainhead for
foundations, which, incidentally, brought peer re-
view into its own.

Now the foundations are in an enviable posi-
tion— if the cash is sufficient — to snatch Medicare
away from the Blues and commercial carriers un-
der a law actually aimed at reducing care costs.
And as the law is presently written, the Blue
plans and insurance companies would have no
recourse. The medical society foundation merely
qualifies as an HMO, and the beneficiary elects
to enroll. Exit the Blue plans and commercial
carriers summarily and without fanfare.

But there are also permissive provisions under
the proposal to permit for-profit corporations to
qualify as HMO's. Enter here professional cor-
porations, also an anathema to the Blues and in-
surers. Nor is this the end of the story, because
the House Committee on Ways and Means stated
in its favorable report on the measure that “your
committee notes that there is sufficient authority
in the present Medicaid program to permit states
to arrange for Medicaid coverage through a

Health Maintenance Organization. It would con-
tinue to be necessary, as required under present
law, to guarantee Medicaid eligibles freedom of
choice of health providers.”

But let none see a pot of gold at the end of
this rainbow just to sate an unwholesome appe-
tite in the delivery of care. It is axiomatic that
the only way to earn money under Part C as now
written is to deliver less care, and this likely would
not be in the interest of the patient. Given a
choice, it is odds-on that few Medicare benefici-
aries would choose HMO services over those of a
private physician except in areas where prepaid
group practice with affiliated hospitals already
abound.

The impact of the proposal is therefore difficult
to assess, although it portends to be massive. We
have problems enough with Medicare and Med-
icaid and little need to invite more and bigger
ones. In the final analysis, worthy, working peer
review and the private delivery system are the
measures of choice in public financing of care for
all patients. Making private delivery continue to
do the job is really the way to stop once and for
all the alphabetizing of the law. — R.B.K.

State Legislation
Is Everybody’s Crisis

In his presidential address at the 102nd An-
nual Session, Dr. James L. Royals reminded us
how Mississippi medicine moved from one legis-
lative crisis to another during two sessions of the
solons in 1969-70. From legislative clearinghouse
reports, other states have this problem, too, with
all sorts of pro and con overtones.

Hawaii and Maryland are faced with bills re-
quiring compulsory areawide planning of hospi-
tals and medical facilities, and a Florida proposal
would give a physician tenure as a hospital staff
member after a year, thereby denying his peers
control over his actions.

If bills in Arizona, California, Georgia, Michi-
gan, New Hampshire, New York, Pennsylvania,
and Virginia are successful, hypodermic syringes
will be Rx only with almost as much paperwork
as a Medicare claim. Hawaii’s lawmakers propose
to guarantee physicians practicing in remote is-
lands an annual income of $36,000, but the mid-
Pacific state would also tie a lot of strings on
them.

Alaska is including abortion in Medicaid,
while Florida has three bills permitting abortion

JULY 1970

389

EDITORIALS / Continued

in the absence of any medical indication. Cali-
fornia’s legislature will vote on a measure to pro-
hibit activities of commercial blood banks.

In Ohio, a bill now pending would prohibit
appearance of a physician as an expert witness
unless all parties to the case were previously
furnished all medical reports pertaining to the
matter at litigation. Florida is looking at a huge
appropriation measure for a new state school of
osteopathy, while California is considering re-
quirements for licensure of professional service
representatives of pharmaceutical manufacturers.

Massachusetts is trying to make physicians
write the generic as well as the brand name on
prescriptions. Florida may make insurance car-
riers and voluntary prepayment sources compen-
sate podiatrists for surgery. Administration of
methadone may become mandatorily reportable
in California.

Pennsylvania has a lulu in a bill which would
permit the state to approve the number of phy-
sicians working in a hospital, approve accounting
procedures under which physicians with hospital-
oriented practices are compensated, and require
financial reports from the hospitals and physi-
cians.

South Dakota is about to require inclusion of
chiropractic benefits in health insurance, and
Kentucky is bringing optometrists into Medicaid.

Most patently bad laws before state legisla-
tures do not pass, while many good laws are en-
acted. But the sum total of the picture is the mas-
sive commitment which a state medical associa-
tion must make to legislative programs in man-
power, time, and money.

They dare not do less, because it takes only
one really bad enactment to exert a tremendously
adverse impact on medical care and those who
provide it. At the national level on Capitol Hill,
AMA is faced with the same problem on a day-
to-day basis.

The Mississippi State Medical Association, mov-
ing from crisis to crisis in the Extraordinary
Session of 1969 and the 1970 Regular Session,
has acted decisively to beef up its own program
with improved communications and commitments
from physicians to work with their senators and
representatives. One-fourth of the dues increase
voted by the 102nd Annual Session is earmarked
for this purpose.

In legislation, what is past is not necessarily
prologue, because every day of a legislative ses-
sion is a new ball game. The urgency of physi-
cian participation in state legislation cannot be

overemphasized. Indifference is our worst enemy
and literally a vote against the goals and objec-
tives of care delivery under our traditional pri-
vate system.

Let’s get ready for the 1971 Regular Session
now. — R.B.K.

CCS Goes to
State Board of Health

On July 1, the state of Mississippi will unite in-
to the health care area a formerly fragmented
state agency, as the Crippled Children’s Service
is transferred from the State Department of Ed-
ucation to the State Board of Health. This action
comes about as a result of an enactment by the
1970 Regular Session of the Legislature which
the state medical association supported.

CCS was organized in Mississippi in 1936 as an
activity of the Vocational Rehabilitation Division,
and it has performed well in the delivery of re-
medial care to children. The $1 million program
is largely federally assisted, and at present, there
are about 20,000 children on its rolls of eligible
beneficiaries. In 1969, the service recorded about
5,500 active cases of eligibles who range from
the newborn to age 21.

The medical director of CCS is the respected
Jackson orthopaedic surgeon, Dr. Thomas H.
Blake, and the administrative director is Mr.
W. P. Bobo. They are assisted by a 19-member
staff which includes one nurse. Traditionally, the
State Board of Health has worked with the pro-
gram, especially in furnishing visiting public
health nursing service. These nurses have been
alert in case finding and referrals, as well as in
post-service follow up visits.

The service conducts clinics regularly at Jack-
son, Clarksdale, Columbus, Tupelo, Greenwood,
Greenville, Vicksburg, Natchez, Gulfport, Pasca-
goula, Laurel, Meridian, and Memphis. Other
clinics are conducted in other Mississippi com-
munities as necessity requires. Clinics are general-
ly oriented to orthopaedic, neurological, urolog-
ical, and surgical conditions. Special emphasis has
been placed on conditions amenable to cardiac
surgery, and some evaluation for epilepsy is in-
cluded.

The primary source of federal funds is the
U. S. Children’s Bureau with some 50-50 match-
ing and some federal assistance requiring no state
matching. The 1971 fiscal year budget, as pro-
vided by the Legislature, is about $1.25 million.

In studies by bodies of the association and in
the major research effort last year, “Information

390

JOURNAL MSM A

ichrocidin" Tablets and Syrup

tracycline HC1— Antihistamine— Analgesic Compound

h tablet contains: ACHROMYCIN® Tetracycline HC1 125 mg.; Phenacetin 120 mg.; Caffeine 30 mg.; Salicylamide 150 mg.; Chlorothen Citrate 25 mg.

"HROCIDIN Tetracycline HC1— Antihistamine— Analgesic Compound Tablets and Syrup are recommended for the treatment
tetracycline-sensitive bacterial infection which may complicate vasomotor rhinitis, sinusitis and other allergic diseases of the
per respiratory tract, and for the concomitant symptomatic relief of headache and nasal congestion. For children and elderly
uients you may prefer caffeine-free ACHROCIDIN Syrup. Each 5 cc contains: ACHROMYCIN Tetracycline equivalent to
tracycline HCI 125 mg.; Phenacetin 120 mg.; Salicylamide 150 mg.; Ascorbic Acid (C) 25 mg.; Pyrilamine Maleate 15 mg.

ntraindications: Hypersensitivity to any
nponent.

lining: In renal impairment, since liver tox-
y is possible, lower doses are indicated; dur-
prolonged therapy consider serum level
erminations. Photodynamic reaction to sun-
!t may occur in hypersensitive persons,
nosensitive individuals should avoid expo-
e; discontinue treatment if skin discomfort
urs.

cautions: Drowsiness, anorexia, slight gas-
distress can occur. In excessive drowsi-
s, consider longer dosage intervals. Persons

on full dosage should not operate vehicles.
Nonsusceptible organisms may overgrow; treat
superinfection appropriately. Treat beta-
hemolytic streptococcal infections at least 10
days to help prevent rheumatic fever or acute
glomerulonephritis. Tetracycline may form a
stable calcium complex in bone-forming tissue
and may cause dental staining during tooth
development (last half of pregnancy, neonatal
period, infancy, early childhood).

Adverse Reactions: Gastrointestinal— anorexia,
nausea, vomiting, diarrhea, stomatitis, glossi-
tis, enterocolitis, pruritus ani. Skin— maculo-

papular and erythematous rashes; exfoliative
dermatitis; photosensitivity; onycholysis, nail
discoloration. Kidney— dose-related rise in
BUN. Hypersensitivity reactions— urticaria,
angioneurotic edema, anaphylaxis. Intracranial
—bulging fontanels in young infants. Teeth—
yellow-brown staining; enamel hypoplasia.
Blood— anemia, thrombocytopenic purpura,
neutropenia, eosinophilia. Liver— cholestasis at
high dosage.

Upon adverse reaction, stop medication and
treat appropriately.

LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 10965

534-9

EDITORIALS / Continued

Systems for Comprehensive Health Planning,”
the state medical association has taken the posi-
tion that many health services for the needy are
unnecessarily separated from primary health-ori-
ented agencies of the state. This remains true to-
day, although the CCS transfer is a logical be-
ginning step to correct this long-standing separa-
tion and fragmentation. The legislation effecting
the change had the support of the Department of
Education and the State Board of Health.

As we move closer to the goals of coordinating
this and similar activities with Medicaid, let us
seek further sensible and reasonable steps to de-
liver care under the aegis of our own state with-
out duplication of effort and expenditure of pub-
lic funds. — R.B.K.

Hellzapoppin’ on
Drug Abuse Bills

Olsen and Johnson, the celebrated comedy
combination of the 1930’s, had a famous routine
about baseball with “who’s on first?” The 2nd
Session of the 91st Congress is little better off
when it comes to the monumental mixup on drug
abuse legislation. Except they seem to have two
runners on first base with both claiming the right
to be there.

Just about everybody agrees that new laws are
needed to combat drug abuse. The major differ-
ences are how it shall be done and whether the
hard liners or liberals shall prevail. Last year, a
senate subcommittee under Sen. Thomas Dodd
(D.,Conn.) conducted hearings, drew a bill, got
it passed in the Senate, and sent it to over to the
House. There, it languishes on the desk of the
aging speaker, John McCormick, gathering dust.

The Dodd bill, S. 3246, resembles a measure
put up by the Nixon administration, generally de-
scribed as the hard line against drug abusers.
Both contain the “no knock” provision permit-
ting search when law enforcement officers have
reason to believe that violations are occurring in
areas normally requiring a search warrant for en-
try.

But worse yet, both measures permit the De-
partment of Justice to rule — over the recommen-
dations of health-oriented agencies and physicians
— what drugs may be included in “abuse cate-
gories.”

Meanwhile, this psychotic Eve of the mysteri-

ously wonderful world of legislation, has a third
face. Rep. Paul Rogers (D.,Fla.) has conducted
hearings on the House side and come up with a
compromise drug abuse bill. In his hearings, Rep.
Rogers took note of scientific and legal witnesses
who testified against Sen. Dodd’s and the admin-
istration’s “no knock” provisions. Whereupon
Sen. Dodd, fighting for his political life in a re-
election campaign, immediately charged that the
scientists were under HEW pressure to testify as
they did on pain of losing lucrative research
grants.

The liberal House Judiciary Committee op-
poses the “no knock” provision which the Senate
has adopted. But the frosting on the cake came a
couple of weeks ago when Chairman Wilbur Mills
(D.,Ark.) of the potent Ways and Means Com-
mittee introduced a fourth version which not only
picks up the provisions of the house-ignored Sen-
ate measure by Sen. Dodd but also contains some
revenue-producing provisions. Under congression-
al rules, this measure may be brought to the
House floor under a gag rule and limited debate.

Now, the vendetta is Justice against HEW in
the executive branch of government, committee
against committee in the House, soft liners versus
hard liners on every side, and a parliamentary
confusion likely to tax Robert and every edition
of his Rules of Order. In the meanwhile, the na-
tion needs new drug abuse legislation and faces a

“Well, so much for its use as a mouthwash

392

JOURNAL MSMA

u are considering weight reduction, consider

phenmetrazine hydrochloride
Endurets®

prolonged-action tablets

Often effective

Controlled studies in a general patient popu-
lation have shown that when Preludin is used
with diet, the rate of weight loss exceeds
that obtained by placebo and diet.

Long acting

Slow, even release of the active principle
usually suppresses appetite continuously for
about 12 hours.

Once-a-day dosage

One Endurets tablet after breakfast. It helps
reduce weight and costs, conveniently.

For contraindications, warning, precautions,
and adverse reactions, please see the full
prescribing information.

It is summarized on this page.

Where there’s no will there’s a therapeutic way.

♦Among persons 20% or more
overweight as compared with
median weight for persons of
like height and sex.

1. Kannel, W.B., et al Circula-
tion 35:734, 1967.

2. Thomas, H.E., Jr., et al.: Med.
Times 95:1099, 1967.

3. Albrink, M.J., in: Beeson,

P.B. & McDermott, W. (eds.):
Cecil-Loeb Textbook of Medicine,
ed. 12, Phila.: W.B. Saunders
Co., 1967.

Preludin®

phenmetrazine hydrochloride

Preludin is indicated only as an
anorexigenic agent in the treat-
ment of obesity. It may be used in
simple obesity and in obesity
complicated by diabetes, mod-
erate hypertension (see Pre-
cautions), or pregnancy (see
Warning).

Contraindications: Severe
coronary artery disease, hyper-
thyroidism, severe hypertension,
nervous instability, and agitated
prepsychotic states. Do not use
with other CNS stimulants,
including MAO inhibitors.
Warning: Do not use during the
first trimester of pregnancy un-
less potential benefits outweigh
possible risks. There have been
clinical reports of congenital mal-
formation, but causal relation-
ship has not been proved. Animal
teratogenic studies have been
inconclusive.

Precautions: Use with caution in
moderate hypertension and
cardiac decompensation. Cases

involving abuse of or depend-
ence on phenmetrazine hydro-
chloride have been reported. In
general, these cases were
characterized by excessive
consumption of the drug for its
central stimulant effect, and have
resulted in a psychotic illness
manifested by restlessness, mood
or behavior changes, hallucina-
tions or delusions. Do not exceed
recommended dosage.

Adverse Reactions: Dryness or
unpleasant taste in the mouth,
urticaria, overstimulation,
insomnia, urinary frequency or
nocturia, dizziness, nausea, or
headache.

Dosage: One 25 mg. tablet b.i.d.
or t.i.d. Or one 75 mg. Endurets
tablet a day, taken by mid-
morning.

Availability: Pink, square, scored
tablets of 25 mg. for b.i.d. or
t.i.d. administration, in bottles of
100 and 1000.

Pink, round Endurets® prolonged-
action tablets of 75 mg. for
once-a-day administration, in
bottles of 100 and 1000.
(B)R3-46-560-B

For complete details, please see
full prescribing information.

Under license from
Boehringer Ingelheim G.m.b.H.

eigy Pharmaceuticals i
ivision of

eigy Chemical Corporation
rdsley, New York 10502

i

CM

9 B- TIM

EDITORIALS / Continued

serious situation with the Supreme Court’s having
softened up many of the laws already on the
books.

The experts on Capitol Hill are quietly laying
odds on Mills who has the advantages of House
rules on his side and the fait accompli Dodd mea-
sure through the Senate. Were it not so serious
and urgent, this comedy of legislative error and
false pride would make humorous reading. But
with the nation consuming stimulant and depres-
sant drugs about 1,000 per cent in excess of max-
imum medical need, nobody with an ounce of
perspective and awareness of the problem is
laughing. — R.B.K.

Aspirin on Rx?
Some Say Yes!

A major U. S. industry — that of manufacturing
aspirin — ought to be shaking in its boots. If it
takes literally the warning and admonitions of
Dr. Richard S. Farr, immediate past president of
the American Academy of Allergy, the aspirin
makers may have thoughts of substantially re-
duced sales.

Dr. Farr, chief of allergy and clinical immunol-
ogy at Denver’s National Jewish Hospital, says
that aspirin ought to be a prescription drug. He
says that his position is supported by the clinical
side effects of the world’s most popular and fre-
quently used pill, and he says that laboratory
findings solidly support the capability of aspirin of
acetylating a wide variety of body substances. He
reports having observed aspirin intolerance in 20
per cent of his patients.

The United States turns out 30 tons of aspirin
each working day. Assuming a huge export mar-
ket, this still adds up to a wallop of tablets for
the pill-consuming public. We are all too acutely
aware that a substantia! number of deaths, par-
ticularly children, are caused each year by as-
pirin poisoning through overdosage.

While the Food and Drug Administration goes
over the deep end to require package insert warn-
ings for oral contraceptives which are not usually
prescribed prior to careful evaluation of the pa-
tient, it appears to let us ingest tons of other
drugs with potentially dangerous consequences.
Maybe we should not put aspirin on a prescrip-
tion basis, but the views of this clinician seem to
underscore how penny wise and pound foolish we
can be with drugs. — R.B.K.

Homicide Increases
in the United States

Death inflicted upon an individual at the hand
of another, homicide, is on the increase in the
United States. The medical implications in this
most revolting of all human behavioral patterns
are clear: Many reasons for the unnatural act
proceed from medical conditions, and for every
successful homicide, there are many which are
unsuccessful, leaving critical injuries to be treated.

The man-killing-man rate in our nation is up
50 per cent over 1950 in the short span of 20
years, and much is being said and studied over
it. Yet, the rate, estimated by the experts to be
about 7.0 per 100,000, is significantly lower than
it was in 1920 through the early 1930’s. Then, it
stood at 8.3 per 100,000 and mounted until it
peaked at 10.0 per 100,000 in 1933, the most vi-
olent year for killings — on a pure statistical basis
— in our history.

Homicide rates, according to actuaries for the
Metropolitan Life Insurance Co. who have made
extensive analyses of killings, vary markedly by
race, sex, and age. For example, deaths among
white females, traditionally the lowest, is at a 50-
year high point.

In the past 10 years, the greatest increase,
however, has been among white males, up by 75
per cent. The rate for nonwhite males surged
ahead about 40 per cent and for nonwhite fe-
males, about 30 per cent. For white females, it
zoomed ahead by 46 per cent.

The race ratio in homicide currently shows
that the rate for nonwhite males is nine times that
of the white rate. For nonwhite females, it is six
times that for white women. The age range in
which the greatest number of killings occur is 25-
34, but the greatest increases are among infants
and the elderly.

Behavioral scientists say that the reasons for
increase in the homicide rate are complex and
not easily explained or understood. Statistically,
rates rise after a war, as in the case of World
War I with the 1920’s, after World War II in
1946, and after the Korean War in 1952 when
the curve took an upward swing. Presumably, the
sharp upswing now noted results to some extent
from the involvement in Viet Nam.

There is a parallel today with the high of the
1920’s in defiance of established authority, and a
disproportionate share of crime is committed by
the young and uprooted poor. The experts also
assert that weakening of traditional disciplines

394

JOURNAL MSMA

contribute to the delinquency of the young, with
the most extreme expression being homicide.

Annual crime reports published by the Federal
Bureau of Investigation place Mississippi last or
near last in homicides, and this is one time it’s
great to be last. The statistics are of interest to
physicians who must see the consequences of
man’s turning on man and who frequently can
diagnose underlying conditions capable of explod-
ing into this ultimate form of violence. — R.B.K.

George Lacey Biles of Sumner, A. V. Beach-
am of Magnolia, and Nelson O. Tyrone of
Prentiss have been re-elected to active member-
ship in the American Academy of General Prac-
tice, upon completing 150 hours of accredited
postgraduate study.

P. Temple Carney of Meridian announces the
opening of his new office at 1411-22nd Avenue,
directly across from Anderson Hospital Emergen-
cy Room. Dr. Carney is a family physician.

Dawson B. Conerly, Jr., of Hattiesburg has
been elected president of the Mississippi chapter,
American College of Surgeons.

Ralph J. Criss, Jr., of Coffeeville has moved
his office to the Coffeeville Clinic.

C. E. Easterly and M. A. Taquino of Biloxi
have moved their offices to 1210 W. Division.

W. R. Eure and Mrs. Eure of Bay Springs re-
cently won the sweepstakes in the exhibit of the
Central Mississippi Rose Society in Jackson. The
Eures have grown roses as a hobby for five years.

Charles A. Hollingshead, formerly of Ellis-
ville, has moved his practice and residence to
Laurel. His new office will be located in the Med-
ical Arts Building, 1203 Jefferson Street.

Louis H. Jobe, retired Army hospital command-
er, has been appointed health director of Harri-
son County and the Biloxi-Gulfport area.

Nancy L. Kliesch announces the opening of her
office for the practice of pediatrics and pediatric
cardiology at 500 A East Woodrow Wilson in
Jackson.

V. E. Landry of Lucedale announces the new
location of his Family, Medical & Surgical Clinic

on Summer Street in the Summer Street Office
Building.

John T. Lane of Biloxi is the new president of
the Gulf Coast Opera Theatre for the 1970-71
season.

Gerald M. Little of Natchez announces the
removal of his office to 140 Jefferson Davis Blvd.

Chester W. Masterson of Vicksburg was in-
stalled as president of the Mississippi Eye, Ear,
Nose and Throat Association at its annual meet-
ing in Biloxi.

S. H. McDonnieal, Jr. and Mrs. McDonnieal
will serve as second vice presidents of the Murrah
High School PTA in Jackson for the 1970-71
school year. Dr. and Mrs. Julian Wiener will
be first vice presidents.

William M. McKell, Jr. of Jackson announces
the relocation of his office at 838 Lakeland Drive.
Dr. McKell limits his practice to internal medicine
and gastroenterology.

Paul H. Moore of Pascagoula was installed as
president of the Medical Alumni Chapter of the
University of Mississippi Alumni Association at
the chapter’s annual assembly in Biloxi in May.

James Clay Hays has associated with William
H. Rosenblatt of Jackson in the practice of
cardiology in Suite 615, Medical Arts Building.
1151 N. State.

W. K. Stowers and K. B. Stowers of Natchez
announce the removal of their offices to 140 Jef-
ferson Davis Blvd.

Lamar Thaggard of Madden has been named
“Mississippi’s Outstanding Livestockman for
1970” by the Mississippi State University Block
and Bridle Club.

Charles C. Tyler of Collins spoke at the Jef-
ferson Davis Baptist Brotherhood meeting at Car-
son Baptist Church in late May.

J. W. Watkins of Quitman is heading the 1970
campaign to raise funds for the Clarke County
Mental Health Association.

Lester D. Webb of Calhoun City has been
named “Alumnus of the Year” of Wood Junior
College. The ceremony took place during recent
Alumni Day activities in Mathison.

Andrew J. Yates of Jackson and Robert C.
Tibbs II of Cleveland have been elected fellows
in the American Academy of Pediatrics.

JULY 1970

397

Summer time. ..monilia time!

No wonder you see so many more cases of vaginal
moniliasis during this season. A damp, warm
bathing suit provides a perfect breeding ground for
fungal invaders. But your patients need not suffer
the pain, the embarrassment and the discomfort
of these stubborn infections. Nor the disappointment
which comes when they find “the cure didn’t take.”

Candeptin avoids disappointment.

With Candeptin, you and your patients have
reason for confidence. A single, 1 4-day course
of therapy with Candeptin is usually
to eradicate the invader, while rapidly
itching, burning, discharge and malodor.

And Candeptin is “cidal” as well as “static”;
100 times more potent than nystatin in vitro,
it has achieved culture-confirmed cure rates of
90% and more (even in notoriously difficult
pregnant patients) . Why not maximize your
chances of success by adopting effective, well-
tolerated Candeptin as your agent of first

Agent of first choice

Candeptin

candicidin VAGINAL TABLETS/OINTMENT

Candeptm ®candicidin

Formula:

Candeptin Vaginal Ointment
contains a dispersion of
candicidin powder equivalent
to 0.6 mg. per gm. or 0.06%
candicidin activity in U.S.P
petrolatum. 3 mg. of candicidin
is contained in 5 gm. of ointment
or one applicatorful. Candeptin
Vaginal Tablets contain
candicidin powder equivalent to
3 mg. (0.3%) candicidin activity
dispersed in starch, lactose and
magnesium stearate.

Indications:

Vaginal moniliasis due to Candida
albicans and other Candida species.

Contraindications:

Patient sensitivity to any of the
components. During pregnancy
manual tablet insertion may be
preferred since the use of the
ointment applicator or tablet
inserter may be contraindicated.

Caution:

Clinical reports of sensitization
or temporary irritation with
Candeptin Vaginal Ointment or
Vaginal Tablets have been
extremely rare. To avoid re-
infection, it is recommended that
the patient refrain from sexual
intercourse during treatment
or the husband wear a condom.

Dosage:

One vaginal applicatorful of
Candeptin Ointment or one
Vaginal Tablet is inserted high
in the vagina, twice a day,
in the morning and at bedtime,
for 14 days. Treatment may be
repeated if symptoms persist
or reappear.

Dosage forms:

Candeptin Vaginal Ointment
is supplied in 75 gm. tubes with
applicator (14-day regimen
requires 2 tubes). Candeptin
Vaginal Tablets are packaged
in boxes of 28, in foil, with
inserter— enough for a full
course of treatment. Store under
refrigeration.

Federal law prohibits dispensing
without prescription. Candeptin
is a registered trade-mark of
Julius Schmid, Inc.

JULIUS SCHMID
PHARMACEUTICALS
New York, N.Y. 10019

The following physicians have been elected to
membership by their respective component medi-
cal societies in the Mississippi State Medical As-
sociation and the American Medical Association.

Evers, Carl Gustav, Jackson. Born Lake Ben-
ton, Minn., July 30, 1934; M.D., University of
Minnesota School of Medicine, Minneapolis,
1959; Interned University Medical Center, Jack-
son, one year; pathology residency, University
Medical Center, Jackson, July 1, 1960-October
31, 1961 and August 1, 1962-March 31, 1964;
elected January, 1970, by Central Medical Socie-
ty-

Kliesch, William Frank, Jackson. Born
Franklinton, Louisiana, Nov. 4, 1928; M.D.,
Louisiana State University School of Medicine,
New Orleans, 1953; Interned Valley Forge Army
Hospital, Phoenixville, Pa., one year; internal
medicine residency, Charity Hospital, New Or-
leans, La., July 1, 1956-June 30, 1957 and
Ochsner Foundation Hospital, New Orleans, La.,
July 1, 1957-June 30, 1959; elected January,
1970, by Central Medical Society.

Graves, Zebulan Butler, Hattiesburg.
M.D., Tulane University School of Medi-
cine, New Orleans, 1926; Interned Hillman Hos-
pital, Birmingham, Ala., one year; died May 18,
1970, age 67.

Moore, Wallace Crockette, Jr., Rose-
dale. M.D., University of Tennessee Col-
lege of Medicine, 1950; Interned John Gaston
Hospital, Memphis, Tennessee, one year; died
May 22, 1970, age 52.

399

MEETINGS

I I

NATIONAL AND REGIONAL

American Medical Association, Annual Conven-
tion, June 20-24, 1971, Atlantic City, Clinical
Convention, Nov. 29-Dec. 2, 1970, Boston.
Ernest B. Howard, Executive Vice President,
535 N. Dearborn St., Chicago, 111. 60610.

Southern Medical Association, 64th Annual
Meeting, Nov. 16-19, 1970, Dallas. Mr. Rob-
ert F. Butts, Executive Director, 2601 High-
land Ave., Birmingham, Ala. 35205.

STATE AND LOCAL

Mississippi State Medical Association, 103rd An-
nual Session, May 3-6, 1971, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Mississippi Academy of General Practice, Annual
Assembly, Oct. 20-22, 1970, Biloxi. Miss Lou-
ise Lacey, Executive Secretary, P. O. Box
1435, Jackson.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centre ville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Howard A. Nelson, 308 Fulton
St., Greenwood, Secretary.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-

400

taurant, Hernando. Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday,
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, April and October. Cherie Friedman,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October, Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell, 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March,
June, September, and December, A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday,
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.
W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m., Old Southern Tea Room, Vicksburg.
Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

JOURNAL MSM A

Ole Miss Medical Alumni House Adds
New Dimension to Med Center Complex

The Medical Alumni House of the University
of Mississippi Medical Center at Jackson was
dedicated at a late afternoon ceremony in the
UMC School of Nursing Auditorium. Dr. Hector
S. Howard of Memphis, medical alumni presi-
dent, presided.

Dr. Howard gave the history of the Medical
Alumni House and recognized the building com-
mittee. Dr. William E. Bowlus of Jackson, chair-
man of the dedication committee, introduced the
dedicatory speaker, Dr. Arthur C. Guyton, chair-

man of the UMC department of physiology and
biophysics.

Dr. Guyton emphasized that the completion of
the alumni house is only a beginning in the total
future plans for the medical center. He called on
the alumni for assistance and support in achiev-
ing other goals including a postgraduate center
and recreational facilities for the medical stu-
dents and their families.

Dr. W. Alton Bryant, vice chancellor of the
University of Mississippi, and Dr. Robert E. Car-

Examining the architect’s rendering of the now-fin-
ished UMC Medical Alumni House are, from left,
Drs. Hector S. Howard of Memphis, medical alumni
president; W. Alton Bryant of Oxford, Ole Miss vice

chancellor; Paul H. Moore of Pascagoula, alumni
president-elect; Howard A. Nelson of Greenwood;
and Robert E. Carter, medical center dean and di-
rector.

40 I

JULY 1970

ORGANIZATION / Continued

ter, dean and director of the University Medical
Center, responded and accepted the dedicatory
remarks.

Dr. J. Daniel Mitchell of Jackson, chairman of
the Finance Committee, dedicated the guest
rooms and the conference room. Dr. Bowlus rec-
ognized the class representatives present.

The three-story, contemporary structure, cost-
ing just under $700,000, offers 40 double rooms
with two suites, a snack bar, conference facili-
ties, and headquarters for the medical alumni of-
fices, according to C. W. Bill Price, alumni sec-
retary at Jackson.

Alumni offices will be on the first floor. Also
located there are the lobby and registration desk,
food service and preparation areas, conference
room, hostess’ apartment, and mechanical rooms.

The alumni house will be available to alumni,
out-of-town visitors to the UMC campus, and
to physicians attending postgraduate training
courses.

The building was constructed with assistance
from the State Building Commission and under-
written by Ole Miss medical alumni. It is expect-
ed to be self-amortizing from room revenues,
food sales, and other sources.

Architects for the building were Bouchillon
and Harris of Jackson, and Jones and Thompson
Construction Company of Jackson was general
contractor.

An informal tour of the Medical Alumni House
preceded the buffet supper following the dedica-
tion.

Dr. Hill Is Named
Delegate to AMA

Dr. Stanley A. Hill of Corinth has been ap-
pointed to serve as delegate to the American
Medical Association from Mississippi. He suc-
ceeds Dr. Howard A. Nelson of Greenwood who
has resigned the post.

The appointment was made by Dr. Paul B.
Brumby of Lexington, association president, who
named Dr. Hill from his former post of alternate
delegate. The unexpired term he will serve con-
tinues through 1970.

Serving with Dr. Hill is Dr. G. Swink Hicks of
Natchez, the association’s senior delegate whose
current term is Jan. 1, 1970, through Dec. 31,
1971. Dr. Joseph B. Rogers of Oxford is alter-
nate delegate to Dr. Hicks with a concurrent
term.

Succeeding Dr. Hill in the alternate delegate
post is Dr. C. D. Taylor, Jr., of Pass Christian,
also an appointee of President Brumby.

Dr. Taylor is a delegate-elect, having been
named to a full regular term by the House of
Delegates at the 102nd Annual Session. He en-
ters office on Jan. 1, 1971, to serve through Dec.
31, 1972. Dr. Hill was re-elected alternate dele-
gate and will assume that office concurrently with
Dr. Taylor’s becoming the delegate on next Jan.
1.

Drs. Hicks and Hill were seated at the recent
Chicago AMA annual convention with Drs. Rog-
ers and Taylor serving as their alternates.

Under the apportionment formula of one AMA
delegate per 1,000 members of AMA or fraction
thereof, Mississippi seats two delegates in the
AMA House.

SAMA Reactivated

at UMC

The Student American Medical Association
chapter at the University of Mississippi School of
Medicine has been reactivated.

Some 77 members from the freshman and
sophomore classes have been recruited. Officers
were elected from the first year students, and
will serve a one-year term.

Newly elected officers are Bill W. Long of
Blue Springs, president; Ray Johnson of Forrest,
vice president; and Sandra Shook of Jackson, sec-
retary-treasurer.

Plans are to hold monthly meetings at noon on
Tuesday. Speakers are being sought on socio-
economic developments as well as medical trends.

Newly elected officers of the University Medical
Center's SAMA chapter are, from left, Sandy Shook
of Jackson, secretary-treasurer; Bill W . Long of Blue
Springs, president; and Ray Johnson of Forrest, vice
president.

402

JOURNAL MSMA

Book Reviews

Manic Depressive Illness. By George Winokur,
M.D., Paula J. Clayton, M.D., and Theodore
Reich, M.D. 186 pages. St. Louis: The C. Y.
Mosby Co., 1969. $6.50.

Written by the psychiatry group at Washington
University, St. Louis, from the classic (descrip-
tion-classification and nomenclature) position
point, this book is a thorough review of manic-
depressive reaction with concise summaries at the
end of each chapter and many paragraphs. It is
reasonably short, thus not cumbersome or boring
to read.

The coverage of and approach to the illness is
from the genetic-epidemiological as well as the
clinical.

Some interesting findings are revealed as a re-
sult of the authors’ clinical research study, e.g.,
the incidence of manic-depressive primary states
are three times that of schizophrenic reactions;
M-D disorders more likely to be associated with
i relapses than depressive disorders and a consid-
erable number will experience only one attack
and most patients do not follow a chronic (con-
tinuous disease) course; none of the obsessional
neurotics had attacks of mania; that bipolar fe-
male patients more likely to attempt suicide (in
depression) but the manic episode lasted half the
time of men, 73 days; the minority of patients
have complete and lasting remissions with depres-
sive symptoms the major problem during follow-
up; a M-D woman with previous postpartum epi-
sode is considered a special risk in subsequent
post-birth periods; major contribution to M-D dis-
ease seems to be from an x-1 inked dominant
gene.

Admittedly, the authors had a small series of
hospital and clinic patients (51) but the method-
ology of their clinical-genetic study, which rig-
orously defined M-D disease, seems painstaking-
ly sound. They do not delude themselves about
the limitations and shortcomings of their study.

The authors point out that the largest part of
the error in the family study is the false-negative,
the person called well by family history but found
afflicted with some mental or emotional disorder

by personal interview. Also that affective illness
is quite likely not to necessitate hospitalization,
more often for mania than depression; and that
depression prior to or after mania is not invari-
able.

The indexing of the symptoms is excellent
from the standpoint of what the patient and fam-
ily report in manias and depressions, the most re-
active symptom, irritability, “perhaps.”

The question of etiology remains a riddle after
a good review of the biologic, psychologic and
social suppositions.

The therapy chapter reminds us of the three-
fold management purposes: (1) prevent serious
social and medical consequences of depression.
(2) temper depressive affect and alleviate guilt
feelings, and (3) help the family understand the
patient and his illness.

Some new empirical combination drug ap-
proaches are briefly discussed in addition to the
more conventional attacks. The authors feel it is
not unreasonable to try new treatments when
other methods have failed and the patient is se-
verely incapacitated.

Robert L. McKinley, Jr., M.D.

Crisis Fleeting. Original Reports on Military
Medicine in India and Burma in the Second
World War. Compiled and edited by James H.
Stone. 423 pages with illustrations. Washington,
D. C.: The U. S. Government Printing Office,
1969. $3.75.

This is a collection of remarkable diaries and
reports written by Army Medical Department
personnel while serving in the India-Burma The-
ater during WWII.

“North Tirap Log,” is a daily diary meticu-
lously recorded between 19 April and 20 Decem-
ber, 1943, by Mr. (then Sgt.) R. M. Fromant
while assigned to an aid station on a foot trail
leading from Assam Provine, India, to the Hu-
kawng Valley of Burma. Here, among steep,
heavily forested hills, such a long way from civili-
zation, they provided medical support to the en-
gineer, quartermaster, signal, and Chinese infan-
try troops painfully making their way into Burma
to claw out a new road through the jungle.

“The Tamraz Diary” is a journal which Col.

JULY 1970

403

THE LITERATURE / Continued

John M. Tamraz, MC, compiled while a senior
surgeon in the China-Burma-India Theater.

“With Wingate’s Chindits” is the final report
on the medical arrangements for the British Spe-
cial Force which fought behind enemy lines in
North Burma in 1944.

“Chinese Liaison Detail’’ is a realistic account
of medical experiences during the unbelievable
struggle to build the Ledo Road.

The controversial exploits of Merrill’s Marau-
ders is further illuminated by “Marauders and
Microbes,” which is a joint personal report by
two physicians who served with the unit during
those exciting events.

These humanized “on the spot” narratives
glow with the vitality of personal experience.
Several hours of fascinating reading is assured,
especially for the physician who has served in ei-
ther the C.B.I. Theater, or in any of the jungles
of the South and Southwest Pacific. The entire
volume adds greatly to the already illustrious mil-
itary medical history of World War II.

Robert E. Blount, M.D.

Dr. Arrington Retires
From Blues Board

On his retirement from the Board of Mississippi
Blue Cross-Blue Shield . Meridian physician, Dr.
G. Lamar Arrington, Sr., received special recognition
from Owen Cooper for his years of service. The
presentation took place at the annual board meeting
in Jackson , at which time John D. Holland of Jack-
son was elected to succeed Owen Cooper as Chair-
man of the Board of Mississippi Hospital and Medi-
cal Service.

AM A Judicial Council
Plans Ethics Congress

The Judicial Council of the American Medical
Association will hold its 3rd National Congress
on Medical Ethics Sept. 19-20.

The meeting will take place at the Ambassador
West Hotel in Chicago.

The program will include panel discussions
and individual speakers addressing ethical issues
of concern to the medical profession.

For further information, write Judicial Coun-
cil, AMA, 535 North Dearborn St., Chicago, 111.
60610.

TELEMED Develops
Multiprocessing Computer

TELEMED Corporation, of Schiller Park, 111.,
has developed an on-line multiprocessing com-
puter facility for real-time analysis of medical
data as an aid to the physician in making diag-
noses.

TELEMED, a subsidiary of MEDEQUIP Cor-
poration of Park Ridge, 111., offers computer anal-
ysis of electrocardiograms through a dual con-
figuration of Xerox Data Systems Sigma 5 com-
puters. The central facility has the capability to
handle up to 8600 ECGs per day by accommo-
dating simultaneous transmission and analysis of
data. Multiple telephone lines connect the central
computer facility to remote coupled ECG units
located in hospitals, diagnostic and industrial clin-
ics, medical centers, nursing and convalescent
homes, and physicians’ offices.

The computer performs an analysis which
measures all pertinent ECG amplitudes and dura-
tions, characterizes the wave forms from each of
the twelve leads of the scalar electrocardiogram,
calculates such factors as rate and electrical axis, ^
and produces an interpretation of the status of the
electrical function of the heart based upon these
parameters. The analysis is then transmitted via ;
telephone line to a teletype unit on the subscrib-
er’s premises, for assessment by the physician.

404

JOURNAL MSMA

Dr. Ainsworth Is
AUA President-Elect

Dr. Temple Ainsworth of Jackson has been
elected president-elect of the American Urolog-
ical Association. He will assume office in May,

The Jackson urolo-
gist was elected at the
association’s annual
meeting in Philadel-
phia, Pa.

A native Mississip-
pi, Dr. Ainsworth
earned his B.S. de-
gree from the Univer-
sity of Mississippi and
his M.D. degree from
the University of Vir-
ginia. He completed
internship and uro-
logical training at the
University of Virginia
Hospital. Dr. Ainsworth was a resident in surgery
at South Mississippi Charity Hospital during
1928-29.

Upon completion of training in 1929, he be-
gan the private practice of urology in Jackson.
He is on the attending staff of the Mississippi
Baptist Hospital, St. Dominic-Jackson Memorial
Hospital, University Hospital, Doctors’ Hospital,
and Hinds General.

Long active in medical organization, Dr. Ains-
worth has served as president of the state medical
association, chaired the association’s Council on
Medical Education for a number of years, and
has been a member of the Council on Medical
Service.

Dr. Ainsworth has served as president of the
Central Medical Society and president of the Mis-
sissippi chapter of the American College of Sur-
geons. He has also been ACS governor for Mis-
sissippi.

He is a diplomate of the American Board of
Urology, and a fellow of the American College
of Surgeons. He holds membership in the Ameri-
can Society for Pediatric Urology, American As-
sociation of Clinical Urologists, and the Society
of University Urologists, the American Medical
Association, and the Southern Medical Associa-
tion.

Dr. Ainsworth served as chairman, department
of urology, and clinical professor of urology, at the
University of Mississippi School of Medicine from
1954-1968. He is also chairman of the Mississippi
Kidney Foundation.

Thoracic Society
Officers Elected

During the Annual Meeting of the Mississippi
Thoracic Society, held in Jackson on Thursday,
April 16, new officers for the 1970-71 year were
elected.

New officers included: Dr. Antone Tannehill,
Jr., Tupelo, president; Dr. Roland B. Robertson,
Jackson, vice-president; Dr. G. Boyd Shaw, Jack-
son, secretary-treasurer; Dr. Guy D. Campbell,
Jackson, ATS Advisory Council member; Dr.
John Williams, Greenville and Dr. John Morgan,
Jackson, Executive Committee members. Dr.
Boyd Shaw will continue serving as Tri-State
Consecutive Case Conference representative for
the Society in planning the program for this
meeting jointly sponsored by the Thoracic So-
cieties and TB-RD Associations of Mississippi,
Alabama and Louisiana.

The scientific session of the one-day annual
meeting included the following guest speakers
and their topics: Dr. John Ochsner, chairman of
department of surgery, Ochsner Foundation Hos-
pital and Clinical Associate Professor, Tulane
University School of Medicine, New Orleans,
speaking on “Bronchial Adenomas” and “Tho-
racic Lesions in the Infant Requiring Urgent
Surgical Care”; and Dr. Joseph Bates, chief of
medicine, V. A. Hospital and associate professor
of medicine, University of Arkansas, Little Rock,
speaking on “Needle Biopsy for Diffuse and
Localized Lesions of the Lungs”; “Pneumonia —
‘Yesterday and Today,’ ” and “Pulmonary Tula-
remia.”

Dr. James Hardy, University Medical Center,
Jackson, presented a special lecture during the
annual meeting luncheon on “Current Status of
Lung Transplants.” In addition, case presenta-
tions were made by the following Society mem-
bers; Dr. Robert Cole, Amory; Dr. Benton Hil-
bun, Tupelo; Dr. John R. Williams, Greenville;
and Dr. Fred Tatum, Hattiesburg.

The Mississippi Thoracic Society serves as the
medical arm of the MTRDA. Physicians inter-
ested in membership in the Society are requested
to direct their inquiries to P.O. Box 9865, Jack-
son, Mississippi.

JULY 1970

405

ORGANIZATION / Continued

Construction Begins on
MHA Headquarters

The Mississippi Heart Association broke
ground for their new headquarters building at
4830 McWillie Circle in North Jackson with an
impressive line-up of dignitaries in attendance.

Dr. Jetson P. Tatum of Meridian, former
MHA president, was master of ceremonies. Dr.
Arthur C. Guyton, professor and chairman of the
department of physiology and biophysics of the
University of Mississippi Medical Center, was
guest speaker for the ceremonies and following
luncheon at Lefleur’s Convention Center. Dr.
Guyton discussed the accomplishments in, and
the future outlook for, heart research in Missis-
sippi.

The late Miss Ethel Ketcham of Jackson be-
queathed to the heart association funds for the
express purpose of purchasing property and with

Breaking ground for the Mississippi Heart As-
sociation’s new headquarters building in Jackson
were, from left, Dr. Arthur C. Guyton of Jackson,
former president and guest speaker for the occasion;
Miss Lucile Little of Jackson, MHA executive di-
rector; Dr. G. Spencer Barnes of Columbus, 1970
president; Ray R. McCullen of Jackson, state trea-
surer and chairman, building committee; and Dr.
Jetson P. Tatum of Meridian, master of ceremonies
and past president.

406

this the lot was bought, according to Dr. G. Spen-
cer Barnes of Columbus, president.

The Building Finance Committee is composed
of Everett Crudup of Meridian, chairman,
Charles R. Sayre of Greenwood, Dr. Frederick
E. Tatum of Hattiesburg, Ray R. McCullen and
Ernest G. Spivey, both of Jackson.

McCullen also chaired the Building Commit-
tee, appointed by Congressman G. V. Montgom-
ery, MHA president in 1968. Spivey and Randal
Craft, also of Jackson, served as members.

John L. Turner and Associates of Jackson are
the architects and Pat Cronin Construction Com-
pany is the builder.

D. A. Grimes Named

UMC Hospital Director

D. Andrew Grimes has been named director
of the University Hospital in Jackson, according
to Dr. Robert E. Carter, director of the Universi-
ty Medical Center.

The Board of Trustees, Institutions of Higher

Learning, formally

Mr. Grimes

approved the ap-
pointment at the May
meeting.

Grimes succeeds
Dr. David Wilson,
who was hospital
head for some 15
years prior to his ele-
vation to assistant di-
rector of the Medical
Center for health
planning in 1969.

The new hospital
director joined the
Mississippi staff in
1967 as associate director. He was previously as-
sistant director at Vanderbilt University Hospital,
administrative research coordinator and assistant
director of the Vanderbilt University Medical
Center in Nashville.

Grimes holds the A.B. degree from Washing-
ton and Jefferson College and the M.S. degree
from the University of Pittsburgh. At Cornell Uni-
versity he had additional training in hospital ad-
ministration.

He is affiliated with the American Hospital
Association, Association of American Medical
Colleges, American College of Hospital Admin-
istrators, Mississippi Hospital Association and So-
ciety of Hospital and Medical Administrators.

JOURNAL MSM A

MSBH Sponsors
Radiological Courses

Courses in radiological health for x-ray tech-
nologists were recently offered by the State Board
of Health, free of charge, in Jackson, Tupelo,
Laurel and Biloxi, according to State Health Of-
ficer Hugh B. Cottrell.

Dr. Cottrell said the Southeastern Radiological
Health Laboratory in Montgomery, Ala., coop-
erated with the Radiological Health Unit of the
State Board of Health in presenting the courses
and furnished a team of instructors.

Serving as coordinators were Ronald J. For-

Isythe and Charles E. Hilton, health physicists in
the Radiological Health Unit.

“Through these courses,” said Forsythe, “we
hope to minimize the danger of radiation expo-
sure to Mississippians who have x-rays performed
for diagnostic interpretation as well as to those
operating the x-ray machines.”

The State Board of Health offered radiological
health courses for x-ray technologists in 1965, but
a rapid transition in technology has taken place
since then, Forsythe pointed out.

A 5-day course, open only to instructors in
x-ray technology, was held June 8-12 at the State
Health Department in Jackson.

“Structured for instructors, this course present-
ed the principles of teaching radiation protection
as well as basic radiological health,” said For-
sythe.

A 2-day course, “designed to create an atmo-
sphere and feeling for radiation protection for
both patient and radiation worker,” was conduct-
ed in four different locations in the state, accord-
ing to Forsythe.

Eligible for this course were professional x-ray
technologists and students who are in the senior
year of x-ray technology and are planning on a
professional career in the field.

Medical Center Graduates 75 M.D/s

At the 14th annual University of Mississippi Med-
ical Center Commencement , 75 received the M.D.
degree; 32, the B.S. in nursing; 11, the Ph.D.; and
four, the M.S. At left, Chancellor Porter L. Fortune
conferred degrees and Judge James P. Coleman of
the U. S. Fifth Circuit Court of Appeals, second left,
was Commencement speaker. Dean of the School of
Medicine Dr. Robert E. Carter, third left, presented

medical degree candidates. Dr. Jerry Clifford Griffin
of Silver Creek, third right, was the recipient of the
Waller S. Leathers Medal, given annually for the
highest four-year medical average, while Mrs. Carol
Ann Sitton McGehee, second right, got the Faculty
Award, which goes to the top nursing student. Miss
Christine L. Oglevee. dean of the School of Nursing,
right, presented nursing degree candidates.

JULY 1970

407

MPAC

AMPAC

give you IMPACT, doctor!

But make it a mutual impact, doctor, because your PAC
needs you and you need your PAC. Both AMPAC and
each of the 50 state PAC’s are voluntary, nonprofit, un-
incorporated, autonomous groups whose members are
physicians, their wives, and others in allied professions.
Every group is bipartisan, bound by no party label. The
voting record, platform, and program of a candidate —
not his party — is what the PAC considers.

The basic purpose is twofold: To educate in political
affairs and to provide a means through which the physi-
cian-citizen can effectively make his voice heard in the po-
litical arena. MPAC is medically oriented and medically
directed by a 10 member board consisting of nine physi-
cians and a Woman’s Auxiliary representative.

With the elections behind, MPAC is looking ahead to
1970 when there will be a job to do. Make your voice
count by sending your dues today, $10 for MPAC and
$10 for AMPAC. Better send dues for your wife, too.

MISSISSIPPI MEDICAL
POLITICAL ACTION
COMMITTEE

408

JOURNAL MSM A

Flying Physicians
Meet in Canada

The 16th annual meeting of the Flying Physi-
cians Association will be held at the Bayshore
Inn, Vancouver, British Columbia on Aug. 23-
28.

It will mark two firsts for the group of flying
doctors: their first convention outside the United
States, and their first yearly meeting in Canada.

Dr. Curtis Caine, Jackson anesthesiologist, will
preside over the five day meeting.

Between 700 and 900 persons are expected to
attend and many of them will fly their own air-
craft to Vancouver International Airport. Tie-
down facilities and space will be required for
more than 200 aircraft.

I The program will include lectures on medical
subjects, aerospace medicine, general aviation
safety, maximum aircraft performance, and other

I related subjects.

Program Chairman Dr. Marvin B. Hays, Eu-
reka, Cal., is also planning a series of round ta-
ble discussions on such subjects as instrument
flight routine versus visual flight routine, how to
survive a crash, ladies in the air, lady pilots, get-

Iting along with the weather, and engine main-
tenance.

Dr. Gordon Hepworth, Vancouver, is serving
j as chairman of the local arrangements commit-
tee. Many of the key speakers will be recruited
locally. Assisting Drs. Hays and Hepworth in this
effort will be Dr. Reginald R. Harper of North
Surrey, British Columbia.

In the exhibit area of the Bayshore Inn, reg-
istrants will have the opportunity to view the lat-
est in medical and aviation products. A number
of manufacturers and scientific organizations will
have exhibits on display. Manufacturers of small
aircraft will have a number of planes on static
display at Vancouver International Airport.

A special program is being planned for the
wives and children who attend the meeting. In
charge of these activities is Mrs. Regionald R.
Harper of North Surrey, B. C.

A portion of the program will be devoted to
the Samaritan activities of the Flying Physicians
Association. Many members are volunteering to
serve in humanitarian projects, such as volunteer
physicians for Viet Nam and Project Hope.

The Flying Physicians Association was started
in 1954 by a group of doctors whose chief objec-
tive was to organize an association of private pi-
lots dedicated to the promotion of general avia-
tion safety through example and teaching.

The Association has grown from its 1955
membership of 700 members to its present mem-
bership of over 2200. This includes members in
the U. S., Canada, Mexico, Puerto Rico, Central
and South America, the West Indies, Australia,
West Germany, England, and the Republic of the
Congo.

Wyeth President Is
Foundation Chairman

Herbert W. Blades, president of Wyeth Lab-
oratories, has been elected chairman of the
board of directors of the Pharmaceutical Manu-
facturers Association Foundation.

The Foundation, established by the Associa-
tion in 1965, is a
non-profit organiza-
tion that supports re-
search, educational
and scientific projects
in the field of clinical
pharmacology and re-
lated disciplines. Its
stated purpose is “to
promote the better-
ment of public health
through scientific and
medical research.”

The PMA Founda-
tion is supported by
voluntary contribu-
tions from about 100 companies and pharma-
ceutical and industry-related organizations and
individuals. Since its formation, the Foundation
has authorized over $2,200,000 to aid a variety
of activities, including: education and training
awards to medical school faculty members and
students in clinical pharmacology, and postdoc-
toral fellowships in pharmacology-morphology;
and fundamental research in areas of drug tox-
icology, such as fetal-neonatal pharmacology, nu-
tritional deficiencies, dialyzable drugs, and ani-
mal-human predictability studies.

The Foundation conducts periodic workshops
and conferences on such topics as drug metabo-
lism and drug evaluation, and continuing educa-
tion programs in drug therapy topics for practic-
ing physicians, hospitals and medical societies.

Mr. Blades is also executive vice president and
a director of Wyeth Laboratories’ parent com-
pany, American Home Products Corporation. He
has been president of Wyeth since 1956, and has
been a director of the Pharmaceutical Manufac-
turers Association since it was founded in 1958.

Mr. Blades

JULY 1970

409

This “case history” runs to some 10,000 pages

This is a typical "case history” of one new drug — or,
rather, a proposed new drug — assembled for submis-
sion to the U.S. Federal Food and Drug Administration,
These volumes are the result of several years' work by
thousands of professional and skilled personnel in
just one pharmaceutical company's research labora-
tories, and by hundreds of physicians in medical
schools, hospitals, and private practice. They cover
every aspect of experience with this proposed new
agent from chemical laboratory to clinic, from mouse
to man. Each volume could conceivably represent
hundreds of thousands of dollars of financial invest-

ment, countless hours of human effort. This veritable
mountain of data stands behind every new agent
offered to you by pharmaceutical manufacturers — a
reassuring testimonial to the efficacy, safety and
purity of the drugs you will prescribe today to lower
the cost of disease to your patients.

Pharmaceutical
Manufacturers Association

Pharmaceutical
Advertising Council

1155 Fifteenth St., N. W„ Washington, D.C. 20005

This message is brought to you as a
courtesy of this publication on behalf of the
producers of prescription drugs.

Burdick

Has the diagnostic equipment in your office kept
pace with your own knowledge of new drugs,
medicines and technics?

Write us for full details on the Burdick EK-IV
Dual-Speed Electrocardiograph.

KAY SURGICAL INC.

663 North State St. • Jackson, Miss. 39201

Index to Advertisers

Arch Laboratories, Div. of Lewis Howe Co 411

Breon Laboratories, Inc 8

Bristol Labs 16, 17

Burroughs-Wellcome 392B

Campbell Soup Company 380A

Conal Pharm. Inc 380D

Dow Chemical Co 3 92 A

Eaton Laboratories, Div. of Norwich Pharmacal 1 1

Flint Laboratories, Div. of Travenol Labs, Inc. 7

Geigy Pharmaceuticals 392D, 393

Hill Crest Hospital 6

Hynson, Westcott and Dunning, Inc 3

Kay Surgical, Inc 411

Leonard Wright Sanatorium 14

Eli Lilly and Company . front cover, 18

Mississippi Hospital and Medical Service 15

MPAC-AMPAC 408

National Drug Company . 384A, 384B, 400A, 400B

Pharmaceutical Manufacturers Association 410

William P. Poythress 392C

Roche Laboratories fourth cover

Schering Corporation 14A, 14B, 14C, 14D

Julius Schmid, Inc 398, 399

G. D. Searle Company 380B, 380C

Stuart Pharmaceuticals, Div. of Atlas

Chemical Industries, Inc second cover

Wyeth Laboratories 395, 396

Lederle Laboratories

4, 10, 12, 391 Thomas Yates and Company

third cover

JULY 1970

411

Vo

New York’s Medicaid program, often called an uncontrolled fiasco
from the beginning, will run up a $1 billion tab in 1970. Pro-
gram in New York City costs about $700 million of which hospitals
get 52 per cent, nursing homes 11 per cent, dentists 9.5 per cent, 1
physicians 6.6 per cent, drugs 5 per cent, and remainder for mis-
cellaneous services. Tn New York City, one out of four citizens ,
is eligible for Medicaid benefits. (

!'!

A shortage of dental manpower that cannot be met within the frame-
work of present dental practice faces the U.S. Dr. John Zapp,
special assistant for dental affairs in HEW is urging organized |!*i
dentistry to assert leadership in expanding use of hygienists and :
assistants before government does it for the profession. t)r. Zapp
believes that more dental schools and expanded classes will not be 1
sufficient to meet the crisis f

Data communications, the business of a computer talking to another
computer or making use of one via long distance, is the hottest ex« 1
panding market in U.S. By 1975, data communications devices marke i
will expand 1,000 per cent and could capture as much as 50 per cen
of the telephone network in another five years. Medicine will com-
pete with business as leading major user of data communications wi
Hospitals, medical schools, and even M.D. *8 using computers.

Child-resistant containers - CRC's - are strongly advocated for R:
packaging by American Academy of Pediatrics, AAP feels that 90 pei
cent of drug poisonings in children under five could be stopped wi*
proper containers. CRC's need not be such that adults have trouble
opening. Specifications for containers are that they should be ef-
fective, simple, and never be made to appear as a toy* In tests,
adult patients with dexterity loss were able to -use CRC's.

School nurse practitioners will be a new breed of semi-autonomous
allied health professionals graduated from University of Colorado
Medical Center. Program aims for postgraduate training after B.S.
in nursing is awarded. SNP's will treat minor illness, do physical
exams, provide immunizations, and be able to assess development an<
behavorial problems in children. New curriculum is being assisted
by a granu to UCMC from Commonwealth Pund.

Th

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Dti

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it

» EDITOR

William M. Dabney, M.D.

* ASSOCIATE EDITORS
George H. Martin, M.D.

Thomas W. Wesson, M.D.

* MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL ASSISTANT
Nola Gibson

PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.
Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

\

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary-Treasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

original papers

Maternal Mortality Related
to Anesthesia ( 1957-

1967) in Mississippi 413 Donald M. Sherline,

M.D.

Resuscitation of the

Newborn 417 Ross E. Smith, M.D., and
Alfred W. Brann, Jr.,
M.D.

SPECIAL ARTICLES

Radiologic Seminar
XCVIII: Duplications of
the Renal Pelvis and

Ureter 424 T. S. McCay, M.D.

Proceedings of the House
of Delegates, 102nd

Annual Session 427 Annual Publication

EDITORIALS

Decision on Abortion:
The Next 90 Days

Is the Muse Usually
Boozed?

The Durability of the
Hill-Burton Act

Muscle Busters Are Not
Dum-dums!

The Bittersweet Issue
of Cyclamates

443 Real or Rhetorical

445 Alcoholic Authors

446 First Veto Loss

446 Sports Science

447 Tip of the Iceberg

THIS MONTH

The President Speaking 442 Our Medical Democracy
Medical Organization 451 103rd Annual Session

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR AUGUST 1970

LSD-Alcoholism Study
Wins Hofheimer Award

A four-year clinical study, which conclusively
disproves claims that LSD is effective in treating
alcoholics, has won the American Psychiatric As-
sociation’s Hofheimer Award for 1970. The Les-
ter N. Hofheimer Prize for Research was pre-
sented to the principal investigators, Drs. Jerome
Levine, and Arnold M. Ludwig, and research as-
sistant Louis H. Stark, A.B., at the annual meet-
ing of the APA in San Francisco.

Dr. Jerome Levine, chief, Psychopharmacology
Research Branch, Division of Extramural Re-
search Programs, National Institute of Mental
Health, and Dr. Arnold M. Ludwig, director of
Education and Research, Mendota State Hospital,
Madison, Wis. began their research investigation of
LSD as a potential treatment agent in 1962, while
serving with the Commissioned Officer Corps at
the former U. S. Public Health Service Hospital in
Lexington, Ky. (now NIMH Clinical Research
Center). They developed and explored the use ot
a specialized LSD technique, known as hypnodelic
therapy, in the treatment of narcotic drug ad-
dicts. In 1964, this study was extended to re-
search on alcoholism at the Mendota State Hos-
pital.

The experience and results have been com- 4
piled and documented in a volume, LSD and
Alcoholism: A Clinical Study of Treatment Ef-
ficacy, to be published by Charles C Thomas,
Springfield, 111. This extensive report includes
sections on background research information; de-
tailed reports of the treatment study, related spe-
cial studies, and follow-up studies of the alcoholic
in the community; and an overview of treatment
efficacy. The emphasis is on evaluation of treat-
ment outcome rather than the treatment process.

The investigators conclude from the findings of
their four-year clinical study that dramatic claims
for the efficacy of LSD treatment in alcoholism
are unjustified.

Dr. Levine has been with the NIMH since
1964, when he was appointed research psychia-
trist and assistant chief of the Psychopharmacol-
ogy Research Branch. In 1967 he was appointed
to his present position. He is also an instructor
in psychiatry at the Johns Hopkins University
School of Medicine in Baltimore, Md. From
1962 to 1964 he served as Assistant Chief Psy-
chiatrist at the U. S. Public Health Service Hos-
pital in Lexington, Ky., and as an instructor in ^
clinical psychiatry at the University of Kentucky
Medical Center in Lexington.

Dr. Ludwig is clinical professor in psychiatry at
the University of Wisconsin Medical Center.

« 4

—The lowest priced tetracycline— nystatin combination available—

August 1970

■r Doctor:

has presented testimony to the Congress agreei ng with the Nixon
: posal to abolish Medicaid in favor of all-federal health program,
i inistration plan is a federal health insurance program for poor
: low income groups now qualified for Medicaid. AMA's Medicredit
gram would have government purchase health insurance for poor and
e tax credits on sliding scale in higher income levels.

Heart of AMA*s Medicredit is a structured peer review
mechanism to guarantee quality and financial success.

Observers look for no action this year, but Senate
Finance Committee has instructed staff to work with
ALIA in preparation of peer review amendments.

: ee of the four CBS-TV stations in Louisiana have offered state
lical society equal time to rebut network *s blast at health care.

: er CBS refused equal time to AMA following slanted ’’Don’t Get
k in America" programs, Louisiana stations took the initiative,
y WWL-TV at New Orleans has balked on action. The two Missis-
pi CBS outlets airing programs made no offer for equal time.

version of hospital accreditation standards adopted by Joint
mission emphasizes the need for physicians on governing boarcTs.
ndards say that "members of the medical staff shall be eligible
, and should be included in, membership on the hospital governing
y. " Revision also says that approval of the medical staff* s by-
s, rules and regulations "shall not be unreasonably withheld."

k for favorable action by the Senate on S.3418 which will give
leal schools federal assistance to train family practitioners.

1 would establish five-year program to expand or begin new CP
idencies and also calls for Secretary of HEW to appoint a 12-
ber Advisory Council on Family Medicine. Move has been sparked
successful program of American Academy of G-eneral Practice.

days of dangerous fireworks are numbered, under recent regula-
rs issued by Food and Drug Administration. Ban forbids inter-
ne shipment of large firecrackers, including cherry bombs, roc-
s, salutes, and aerial bombs. Individual fireworks pieces and
ponents with more than two grains of powder fall under order.

Sincerely,

Howland B. Kennedy
Executive Secretary

THE JOURNAL FOR AUGUST 1970

1 0

NIH Provides
Nursing Grants

New grants from the Division of Nursing are
helping financially distressed nursing schools to
remain operational until students who have al-
ready invested time and money in nursing educa-
tion can graduate as scheduled and engage in
nursing practice. The Division of Nursing is the
nursing component of the Bureau of Health
Professions Education and Manpower Training,
National Institutes of Health.

A Special Project Grant of $44,649 has been
awarded to the Memorial Mission Hospital School
of Nursing at Asheville, N. C. These funds are
aiding this 76 year-old nursing education institu-
tion in the Appalachia area to complete the prep-
aration of its last class — 26 students who began
their training in 1968 and are scheduled to grad-
uate in 1971.

As a result of a Special Project Grant of
$246,162, the Capital City School of Nursing in
Washington, D. C., is proceeding to complete the
training of its last two classes. The total Federal
investment in helping this 93 year-old school to
graduate 40 new nurses in 1971 and an additional
40 in 1972 is expected to reach $365,962.

Further information about Special Project

Grants as authorized by the Health Manpower Act,
and how they serve to start new schools of nurs-
ing and to help existing schools remain in op-
eration and produce greater numbers of well- '
prepared nurse practitioners may be requested
from the Division of Nursing, 9000 Rockville
Pike, Bethesda, Md. 20014.

Symposium on
Prevention Released

Information of special interest to practicing
physicians, internists and cardiologists is contained
in a new Heart Association publication on pre-
ventive cardiology.

Named “Reducing the Risk of Coronary and j
Hypertensive Disease,” the book stems from the
Minnesota Symposium on Prevention in Cardiolo- '
gy which the Minnesota Heart Association spon-
sored in cooperation with the Mayo Clinic,
Mayo Foundation, University of Minnesota, and l
American Heart Association's Council on Clinical 1
Cardiology.

Edited by Henry Blackburn and Jennifer Willis, |
the book's 25 articles cover the several risk factors
and provide practical suggestions for reducing
the risk by controlling hypertension, diet, obesity, j
cigarette smoking and physical activity.

vjjiff C /test

HOSPITAL

Hill Crest Foundation, Inc.

7000 5TH AVENUE SOUTH
Box 2896,

Birmingham, Alabama 35212

Phone: 205-836-7201

A patient centered
non-profit hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 45 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James K. Ward, M.D., F.A.P.A.

CLINICAL DIRECTOR:

Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL';

Hill Crest is fully accredited by the Joint
Commission on Accreditation ol Hospitals
and is also approved for Medicare pa-
tients.

Cnest

HOSPITAL

BIRMINGHAM, ALABAMA

1 I

1

1 Miss Pot Plot Oxford - A "secret" marijuana plot, one of
: Thieves Target several maintained by the Ole Miss School of

Pharmacy, was raided by thieves who stripped
mature cannabis plants. Site of raid was near Wiggins in Stone
:nty. Project enabling Ole Miss to be the only legal pot farmer
U.S. is pharmacological investigation of different types of mari-
na. Prior to this research, investigators had available only
, icit samples of uncertain origin and age with which to work.

;Polio Deaths Atlanta - The U.S. Public Health Service Com-

I orded in 1969 municable Disease Center reports that not a

single death from poliomyelitis was recorded
the United States last year. Only 19 cases of paralytic polio
e reported, and among these only one patient had received the
cine. In 1954, USPHS recorded 1,400 polio deaths and more than
000 paralytic cases. During 1969, about 26.5 million doses of
cine were administered.

k Force Sacks Washington - The 27-member health care task

[ vate Care force headed by the controversial Blue Cross

national president, Walter J. McNemey, says
:,t it's too late to patch up the present private care delivery
tern and that the nation needs a totally new program. Three point
nposal would replace Medicaid with a federal program, set up a new
k force to write a national health insurance plan, and put new
>hasis on prepaid group practice or closed panel care.

ir Seasons Goes Oklahoma City - Four Seasons Pursing Centers of

;o Bankruptcy America, biggest builder and operator of extended

care facilities and child care centers, has filed
* bankruptcy in federal court. In 1969, Four Seasons was considered
)lue chip stock on the American Exchange, but trading was suspended
it April after it plummeted to the bottom. Last two quarters show-
losses of about $1 million. Four Seasons became third major U.S.
7?oration to go under this year, joining Penn Central Railroad and
-ly Madison Industries.

lering-Plough New York - The prosperous ethical drug firm,

,’ger Is Set Schering, and Memphis-based Plough, Inc. , will

merge to form a powerful ethical and over- the-
ater combine. Plough is best known for St. Joseph and Coppertone
les and actually boasts annual sales greater than Schering. Since
)rganizing in U.S. after having alien status from Nazi Germany,
lering has prospered under superb management. Its stock has split
)-for-one on two occasions, increasing 700 per cent in value.

THE JOURNAL FOR AUGUST 1970

1 4

AMA Honors
Science Students

Two 1 7-year-old high school students were
awarded the top honors of the American Medical
Association during the 21st International Science
Fair in Baltimore, May 1 1-15.

They are Beverly A. Fordham, a junior at
Bryan Adams High School in Dallas, Tex., and
Kevin J. Boran, a senior at Lawton’s Hill School
in Pottsville, Pa.

In addition to their citations presented at the
Health Awards Banquet by Dr. Gerald D. Dor-
man, president of the American Medical Associa-
tion, they were honored guests and exhibitors at
the AMA Annual Convention in Chicago, June
21-25.

They were selected for the AMA honors by a
team of judges, members of the AMA Council on
Scientific Assembly, chaired by Dr. Charles D.
Bussey, Dallas, Tex.

Other winners, who received Awards of Merit
from the AMA, were: Cheryl M. Engleman of
Hazelton, N. D., James M. Gaither, Evansville,
Ind.; Greg Kauffman, Albuquerque, N. M., and
Kathy Wendt, Fairmont, Minn.

The six students were selected for their ex-
hibits in health studies. Competing students to-

taled 402 exhibitors from 45 states, the District
of Columbia, Puerto Rico, Canada, Brazil, Japan,
the Philippines, Sweden and Switzerland.

Miss Fordham’s exhibit was entitled, “Deter-
mination of Alpha Vigilance Via Electroen-
cephalography,” and Boran’s was a study of “The
Effects of Antidiuretic Hormone on Sweating Ac-
tivity and Sweat Composition.” Both exhibited
in the International Amphitheatre throughout the
AMA Annual Convention.

The AMA has participated in the Internation-
al Science Fair since 1956 as part of its program
to attract superior students to the study of the
health sciences.

Miami Offers
Otolaryngology Course

The University of Miami School of Medicine,
Division of Otolaryngology, is presenting a post-
graduate course in ENT for the Family Practi-
tioner.

The course will offer 10 A.A.G.P. credit
hours, and will be held Nov. 13-14, 1970, at the
Sheraton Four-Ambassadors Hotel in Miami, Fla.

Course Director is Dr. Fredric W. Pullen II,
Neuro-Otologic Laboratory, University of Miami
School of Medicine, P. O. Box 875, Biscayne
Annex, Miami, Fla. 33152.

LEONARD WRIGHT SANATORIUM

BYHALIA, MISSISSIPPI 3861 I TELEPHONE A/C 601, 838-2162

LEONARD D. WRIGHT, SR., B.S., M.D., PSYCHIATRY

• Established in 1948. Specializing in the treatment of ALCO-
HOLISM and DRUG ADDICTIONS with a capacity limited
to insure individual treatment. Only voluntary admissions ac-
cepted.

• Located 25 miles S. E. of Memphis-Highway 78 on 20 acres
of beautifully landscaped grounds sufficiently removed to
provide restful surroundings.

• The Sanatorium is approved by The Commission on Hospital
Care in the State of Mississippi.

< unique opportunity to invest in the

health of America:

agine being paid for service to
ousands of people who may
ver visit your office, and may
ver take any of your time at all!

; service is called "Multiphasic
eening.” You know of it, of course,

I no doubt recognize that some
n of low-cost preventive medicine
jrs the only real hope for relieving
growing crisis of medical care for
expanding population.

;onsider an entirely new field that
help Americans everywhere lead
ger, healthier and more produc-
lives — through a revolutionary
thod of early disease detection,
nsider that 40% to 50% of those
Pd have a serious disease or dis-
er-and it will hardly surprise you
t there’s a broad market for Multi-
isic Screening.

Now you can invest

intil now, there were practically
investment opportunties in this
1 Today, however. Health Screen-
Centers, Inc., offers you an invita-
i that changes all that. Now, you
invest in this new and exciting
a of preventive medicine, and take
active role in its growth and
elopment.

rofessionally, you will find this
h of the most satisfying invest-
nts you can make. And, with your
cial knowledge and background
lus the assistance we give you-
; can also be the most profitable
i sstment you're ever likely to make.

What is HSC?

iealth Screening Centers, Inc., has
in organized to coordinate the
nsing and operation of a nation-
e network of early disease detec-
i centers — mobile and in-plant-
izing automated, miniaturized.
Tronic and computerized equip-
nt.

special staff is trained to operate
facilities and to provide efficient.
' '-cost delivery of accurate labora-
/ and physiological test results to
erri ng physicians. A basic HSC
ility of prime van and trailer is
i iipped for fundamental health his-
/ review and dozens of tests, in-
ding: six cardio-pulmonary. three
i rometry, six opthalmologic. twelve
od chemistries, together with a
natology survey, urinalysis and
nm chest X-ray, plus a deter-
nation of diabetes and heart
jble potential.

he whole procedure is performed
the spot — just one hour per indi-
ual at a cost of only $35-and as
i can see does not involve the
ctice of medicine in any way. HSC
iply sends to the referring physi-
n computerized test results which
him in his diagnosis and possible
atment.

Unlimited market

Think of the possibilities for a
mobile multiphasic screening unit in
your area: company employees,
union members, school children,
and perhaps some unstructured in-
digent groups such as Indians, rural
laborers, migrant farm workers. The
need is well established. You will be
bringing this vital low-cost preventive
medicine to the very doorstep of
these people — half of whom will not
take themselves to a physician until
obvious symptoms appear, which
may be too late!

As surely as this service has
humanitarian overtones, just as
surely are you entitled to a profitable
return on your investment. As a med-
ical man. no one is better qualified
than you to take part in this worth-
while enterprise. We want you to
succeed. We help you to succeed.

How HSC helps the Licensee

Health Screening Centers. Inc.,
makes continuously available to in-
vestor groups the necessary techno-
logical counsel, sales guidance and
legal advice. HSC will help you with
initial new-business solicitations, ad-
vertising. publicity, recruitment of
sales and operating personnel. At
Denver headquarters. HSC will
thoroughly train a staff to operate a
mobile or in-plant facility. HSC will
assist with all start-up procedures-
in short, everything you need to suc-
cessfully operate your own health
screening center.

Ground-floor opportunity

Granted. Health Screening Centers.
Inc., is a new name — but so isthevery
concept of multiphasic screening to
the layman. Anticipating the growing
national awareness of the need for
early disease detection, HSC offers
this unique opportunity to get in on
the ground floor" of this business of
screening the sick from the well . . . an
activity that need take very little of
your valuable time.

The other rewards

The physician derives deepest sat-
isfaction from his particular contri-
bution to the well-being of the indi-
vidual, the community, the society.
Yet, chances are. your present in-
vestments are far afield from your
basic desire to solve problems in your
own profession. Thus. HSC is proud
to offer a new dimension to your pro-
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Send for complete facts

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Simply mail your request on your
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East Louisiana, Denver. Colorado
80222. Or call collect: (303) 757-7409.

Health Screening Centers, Inc.

Early Disease Detection — Aid to Preventive Medicine

A. H. Robins
Acquires IUD

A. H. Robins Company has acquired the
Daikon Shield™, an intrauterine contraceptive de-
vice, it was announced today by E. Claiborne
Robins, chairman of the board and chief execu-
tive officer of the Richmond-based pharmaceutical
manufacturer.

The product and its patent rights were pur-
chased from the Daikon Corporation of Green-
wich, Conn., for an undisclosed amount of cash.

The device was introduced commercially to
the medical profession in November 1969. In
clinical tests, the device has shown promise of a
lower incidence of spontaneous expulsion,
cramping and bleeding than other intrauterine
devices. These same tests suggested that the de-
vice may also offer greater protection against
pregnancy than other intrauterine devices.

The Daikon Shield, which marks A. H. Robins
entry into the field of medical devices, will be add-
ed to the company’s present product line and pro-
moted by its medical service representatives.

Viet Nam Volunteer
Program Cited

Dr. Norman W. Hoover, director of the Ameri-
can Medical Association Department of Interna-
tional Medicine, accepted the “Silver Anvil”
award May 14 at the Plaza Hotel, New York City,
on behalf of the AMA’s Volunteer Physicians for
Viet Nam program. It was the top award present-
ed by the Public Relations Society of America
in the category of international relations.

In accepting the trophy from Donald B. Mc-
Cammond, PRSA chairman of the board and
president. Dr. Hoover asked that the honor be
shared by the AMA and the Agency for Interna-
tional Development, U. S. Department of State.
Both organizations have cooperated in the Viet
Nam program for over four years in providing
civilian physicians to work in provincial hospitals.

Silver Anvil awards have been presented each
year since 1944 to acknowledge outstanding pub-
lic relations programs. The anvil represents pub-
lic relations activities measured “on the anvil of
public opinion.”

Brief Summary of Prescribing Information—

9-9/22/69. For complete information consult
Official Package Circular.

Indications: Essential hypertension. Use cau-
tiously in patients with renal insufficiency,
particularly if they are digitalized.
Contraindications: Anuria, oliguria, active
peptic ulceration, ulcerative colitis, severe de-
pression or hypersensitivity to its components
contraindicates the use of Salutensin.
Warnings: Small-bowel lesions (obstruction,
hemorrhage, perforation and death) have
occurred during therapy with enteric-coated
formulations containing potassium, with or
without thiazides. Such potassium formula-
tions should be used with Salutensin only
when indicated and should be discontinued
immediately if abdominal pain, distension,
nausea, vomiting or gastrointestinal bleeding
occurs. Use cautiously, and only when deemed
essential, in fertile, pregnant or lactating pa-
tients. Use in Pregnancy: Thiazides cross the
placenta and can cause fetal or neonatal
hyperbilirubinemia, thrombocytopenia,
altered carbohydrate metabolism and possibly
electrolyte disturbances. Fatal reactions may
occur with reserpine during electroshock
therapy; discontinue Salutensin 2 weeks be-
fore such therapy. Increased respiratory
secretions, nasal congestion, cyanosis and
anorexia may occur in infants born to reser-
pine-treated mothers.

Precautions: Azotemia, hypochloremia, hypo-
natremia, hypochloremic alkalosis and hypo-
kaliemia (especially with hepatic cirrhosis
and corticosteroid therapy) may occur, par-
ticularly with pre-existing vomiting and diar-
rhea. Potassium loss or protoveratrine A may
cause digitalis intoxication. Potassium loss
responds to potassium-rich foods, potassium
chloride or, if necessary, discontinuation of
therapy. Stop therapy if protoveratrine A
induces digitalis intoxication. Serum am-
monia elevation may precipitate coma in
precomatose hepatic cirrhotics. Discontinue
therapy 2 weeks before surgery or if myo-
cardial irritability, progressive azotemia or
severe depression occur. Exercise caution in
patients with chronie uremia, angina pec-
toris, coronary thrombosis or extensive cere-
bral vascular disease or bronchial asthma and
in those with a history of peptic ulceration or
bronchial asthma; in post-sympathectomy pa-
tients; in patients on quinidine; and in pa-
tients with gallstones, in whom biliary colic
may occur. Patients who have diabetes
mellitus or who are suspected of being pre-
diabetic should be kept under close observa-
tion if treated with this agent.

Adverse Reactions: Hydroflumethiazide: Skin
rashes (including exfoliative dermatitis), skin
photosensitivity, urticaria, necrotizing angiitis,
xanthopsia, granulocytopenia, aplastic
anemia, orthostatic hypotension (potentiated
with alcohol, barbiturates or narcotics), aller-
gic glomerulonephritis, acute pancreatitis,
liver involvement (intrahepatic cholestatic
jaundice), purpura plus or minus throm-
bocytopenia, hyperuricemia, hyperglycemia,
glycosuria, malaise, weakness, dizziness, fa-
tigue, paresthesias, muscle cramps, skin rash,
epigastric distress, vomiting, diarrhea and
constipation. Reserpine: Depression, peptic
ulceration, diarrhea, Parkinsonism, nasal stuf-
finess, dryness of the mouth, weight gain,
impotence or decreased libido, conjunctival
injection, dull sensorium, deafness, glaucoma,
uveitis, optic atrophy, and, with overdosage,
agitation, insomnia and nightmares. Proto-
veratrine A: Nausea, vomiting, cardiac ar-
rhythmia, prostration, blurring vision, mental
confusion, excessive hypotension and brady-
cardia. (Treat bradycardia with atropine and
hypotension with vasopressors.)

Usual Dose: 1 tablet b.i.d.

Supplied: Bottles of 60, 600, and 1000 scored
50 mg. tablets.

Salutensin

hydroflumethiazide, 50 mg. /reserpine,
0.125 mg. protoveratrine A, 0.2 mg.

BRISTOL LABORATORIES
Division of Bristol-Myers Company
Syracuse, New York 13201

BRISTOL

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

August 1970, Vol. XI, No. 8

Maternal Mortality Related to Anesthesia

(1957-1967) in Mississippi

DONALD M. SHERLINE, M.D.

Jackson, Mississippi

The study of maternal mortality as it relates
to a particular medical discipline has always
been of interest to the alert physician in his
quest for medical excellence. The Maternal and
Child Care Committee of the Mississippi State
Medical Association in conjunction with the State
Board of Health reviewed its first case in 1957.
During the period 1957-1967 (11 years) there
were 681,081 live births in the state and 542 ma-
ternal deaths, a maternal death rate of 7.9/10,000
live births. This report is concerned with the nine
maternal deaths (1.7 per cent) reported as di-
rectly related to anesthesia.

In 1968, Dr. Augusta Webster presented an
analysis of maternal deaths in Cook County Hos-
pital in Chicago during the period 1952-1965
(13 years). There were 226,878 live births and
234 maternal deaths, a maternal death rate of
10.3/10,000 live births. Of particular interest is
the fact that there were eight maternal deaths
(3.4 per cent) directly related to anesthesia.1

Read before the Section on Obstetrics and Gynecology,
102nd Annual Session, Mississippi State Medical As-
sociation. Biloxi, May 12. 1970.

From the Departments of Obstetrics and Gynecology
and Anesthesiology, University of Mississippi School
of Medicine.

Both Bonica and Eastman in their excellent
textbooks note that anesthesia usually accounts
for 5 to 10 per cent of maternal deaths, yet in
our series and two others that are comparable,
we find that all three are lower than these esti-
mates.2’ 3

The author compares the circumstances
of maternal deaths related primarily to anes-
thesia in Mississippi, North Carolina, and
Chicago’s Cook County Hospital. He dis-
cusses usage of spinal block and general
anesthesia and points out special complica-
tions to watch for.

Maternal Deaths
Primarily Related to Anesthesia

State of Mississippi 1.7 per cent

Cook County Hospital, Chicago 3.4 per cent
North Carolina4 2.9 per cent

It is of interest to speculate on the reasons for
this difference:

(1) All three areas, Cook County Hospital,

AUGUST 1970

413

MATERNAL MORTALITY / Sherline

North Carolina, and Mississippi suffer from a
chronic shortage of adequately trained personnel
to fully provide obstetrical anesthesia. Thus, the
use of anesthesia in obstetrical cases would most
likely fall well below the national average.

(2) In Mississippi and North Carolina it would
also logically follow that local infiltration and
pudendal block would be employed in a high per-
centage of patients receiving anesthesia for rou-
tine deliveries outside of the larger hospitals.
This would tend to reduce the complication rate.
This is also true in the Cook County Hospital
series, where medical students and interns man-
age a great number of the deliveries.

Another corollary of this shortage of anes-
thesiologists, however, is that other physicians,
nurses, and ancillary personnel must extend them-
selves and the complication rate for those cases
administered anesthesia by this relatively in-
experienced group could be expected to be higher.
The source of anesthesia for the Mississippi se-
ries is outlined in Table 1. In only one case was
an M.D. anesthesiologist in consultation.

INADEQUATE CASE FINDING

(3) Lack of adequate case finding could be im-
plicated. In the state of Mississippi the only for-
mal source of cases is the death certificate. If the
fact that the patient was pregnant or recently
pregnant is not recorded, the case may be missed.

(4) Maternal mortality review is through a
questionnaire submitted to the attending physi-
cian. Often the questionnaire is not fully com-
pleted and maternal deaths as a result of anes-
thetic complications might not be recorded. In
1966, 26 per cent of the replies (8 cases) were
not satisfactory for review. Individual hospital
charts are not reviewed and the attending phy-
sician is not interviewed.

TABLE 1

SOURCE OF ANESTHESIA
(MISSISSIPPI)

M.D. anesthesiologist 1

M.D 6

Nurse 1

Not stated 1

The Cook County Hospital and the Mississippi
series are quite comparable in type of anes-
thesia, obstetrical indications and the complica-
tions encountered. In Mississippi there were six

deaths related to spinal block and three to gen-
eral anesthesia. Five deaths were related to
cesarean section, two to vaginal delivery and two
to sepsis complicating abortion (Table 2). The
very similar Cook County Hospital statistics are
presented in Table 3.

Regional and general anesthesia in pregnancy
present some special problems. Usually they can
be avoided if they are anticipated, but prompt
recognition and proper management of difficul-
ties that do arise usually prevent serious com-
plications. The most important of these prob-
lems are discussed below.

SPINAL ANESTHESIA

Standard spinal block anesthesia in the United
States for both vaginal delivery and cesarean
section is a single injection hyperbaric technique
using a single anesthetic agent with a vasocon-
strictor if prolongation of the block is necessary.
One death in the Mississippi series was re-
lated to use of an isobaric continuous technique
using a mixture of drugs.

Drug dosage for obstetrical spinals has been
established at two-thirds to three-fourths of the
dose used in the non-pregnant patient (Table 4).
Failure to stay below the maximum recommended
figures will lead to high levels inappropriate for
the procedure.

The block established with procaine cannot
be expected to last more than 45 minutes. It is
thus unacceptable for most cesarean sections.
Lidocaine, when combined with phenylephrine
3 mg., will maintain an adequate level for only
60 to 75 minutes and should only be used if the
procedure can be safely completed within that
time limit. Both tetracaine and dibucaine should
maintain the level of anesthesia long enough for
the average operator to finish a cesarean section
without difficulty.

HYPOTENSIVE COMPLICATIONS

Hypotension is the most common complica-
tion with spinal anesthesia in pregnancy, even
when staying within the recommended dose
levels. The percentage of cases having significant
hypotension (below 100 mm Hg systolic or
two-thirds the preblock level) will rise as the
block level rises. An appropriate level for a
vaginal delivery is T10-12, and at that level
about 18 per cent will have some hypotension.
If the level rises to T4, 85 per cent may be ex-
pected to have some hypotension.5

The etiology of this hypotension as related to
anesthesia in the obstetrical patient is usually
either vena caval and aortic occlusion or sympa-

4 1 4

JOURNAL MSM A

TABLE 2

ANESTHESIA DEATHS IN MISSISSIPPI, 1957-1967

Anesthesia

Year

Indication

Anesthesia Time

Cause of Death

Spinal

1957

Vag. del.

30 min.

Cardiac arrest

1959

C-section

2 hrs.

Cardiac arrest

1959

C-section

2 hrs., 30 min.

Cardiac arrest

1960

C-section

5 min.

Cardiac arrest

1960

Vag. del.

30 min.

Cardiac arrest

1962

C-section

30 min.

Cardiac arrest

General

1958

Abortion

?

Cardiac arrest

1958

C-section

1 hr., 45 min.

Aspiration pneumonia

1965

Abortion

?

Cardiac arrest

thetic block

and peripheral

vasodilatation in a

3. Straight leg raising.

patient with

a borderline or <

depleted intravascu-

4. Maternal oxygen.

lar volume.

Other causes of hypotension such as

5. Lastly, vasopressors,

preferably methenter-

anaphylaxis should always be kept in mind, how-

mine or ephedrine. Both of these agents are cardi-

ever.

ac stimulators and probably do not decrease

All physicians administering spinal anesthesia
must be prepared to find and treat post-block
hypotension by following a predetermined regime.
First, extremely close monitoring of the patient
is necessary. Post-spinal anxiety and nausea and
vomiting must be correctly interpreted as most
likely due to rapid change in blood pressure.
Hypotension can occur at any time after the
block is administered, and simply because the
medication has “set” and the level stable does
not mean vigilance can be lessened. If personnel
are not available to monitor the block closely,
the wisdom of using this form of anesthesia must
be seriously questioned. Cardiac arrest rarely
arises without warning but only after a period of
hypotension and decreased cardiac and brain
perfusion.

AUTOMATIC RESPONSE

When hypotension is detected, the response
should be automatic:

1. Increase the rate of infusion of intravenous

fluids. Although 5 per cent Dextrose in water is
the fluid used most commonly, its effect on
blood pressure is extremely transient. Ringers
lactate solution is better because it will support
blood pressure extremely well.

2. Left uterine displacement, either manually
or by tilting the patient onto her left side. Alter-
nating sides every two minutes until the block
has set will help insure an equal take.

If the blood pressure does not respond im-
mediately and reach 100 mm Hg after 30-40
seconds of left uterine displacement and/or 200-
300 cc of Ringer’s lactate, the following addition-
al steps will be needed:

peripheral perfusion. Methoxamine, phenyleph-
rine and levarterenol are contraindicated in the
obstetrical patient. They produce their blood
pressure effect primarily by peripheral vasocon-
striction and not cardiac stimulation. This reduces
uterine blood flow and decreases placental per-
fusion. A fetus already in jeopardy may be un-
able to compensate and may either expire or
develop hypoxia and cerebral damage.

RESPIRATORY DEPRESSION

Post-spinal respiratory depression is closely re-
lated to drug dosage, block level and airway man-
agement. Slight depression will require maternal
oxygen. More serious depression of respiration
or apnea will require ventilatory support. This
can quite often be given by mask with assisted
or controlled ventilation with the gas anesthetic
machine. The normal progression of ventilatory
support would be mask, then mask and pharyn-
geal airway, and if respiratory obstruction is
still present or exchange inadequate, endotracheal
intubation. Because of the unpredictability of
complications following regional anesthesia the
physician utilizing these techniques must have
immediately available and be proficient in the
use of masks, laryngoscope, endotracheal tubes,
and a source of positive pressure oxygen (prefer-
ably a standard gas anesthesia machine). He
must also be thoroughly familiar with those anes-
thetic techniques and drugs which are necessary
to prevent an anesthetic catastrophe.

GENERAL ANESTHESIA

Utilization of general anesthesia by whatever
technique also implies an intimate knowledge of

■'i i

•c: i
"5 I

AUGUST 1970

415

MATERNAL MORTALITY / Sherline

obstetrical anesthetic indications, contraindica-
tons and techniques.

Once labor has begun, it must be assumed
that digestion stops and that whatever is already
in the stomach, or is placed there subsequently,
will stay there. We are sometimes lulled into a
sense of false security as in a case recently re-
ported in which an apparently properly prepared
obstetrical patient undergoing cervical circlage
for an incompetent cervix aspirated gastric juice
and had a prolonged and stormy recovery.8 All
obstetrical patients must be presumed to have
either fluid or solid gastric contents. Endotracheal
intubation will afford the safest anesthesia when
surgical planes of general anesthesia must be
used.

COMBINED TECHNIQUES

Flowers makes a strong plea for combined
pudendal block and general analgesia rather
than general anesthesia alone.9’ 10 This technique
utilizes low concentrations of nitrous oxide and
methoxyflurane for minimal newborn and ma-
ternal depression.

Many people feel that the continued use of
cyclopropane in modern obstetrics must be seri-
ously questioned. The explosive and aspiration
hazards outweigh by far any advantage of speed
that cyclopropane may have for obstetrical anes-
thesia. There is no mention made of exogenous
epinephrine, oxytocin, atropine or succinylcholine

TABLE 3

COOK COUNTY HOSPITAL ANESTHESIA
DEATHS

(MATERNAL MORTALITY)

Anesthetic Technique

Spinal 3

General 3

Combined (Spinal/General) . 2

Obstetrical Indications

Cesarean section 5

Vaginal delivery 2

Laparotomy 1

Appendectomy 1

in the protocols of the patients that died when
cyclopropane was being used. Any of these drugs
in combination with cyclopropane, particularly
when associated with an increased arterial par-
tial pressure of C02, increases the risk of cardiac
arrhythmia and possible ventricular fibrillation.

416

TABLE 4

USUAL AND MAXIMUM SAFE DOSAGES OF
VARIOUS LOCAL ANESTHETIC AGENTS
IN OBSTETRICAL SPINAL ANESTHESIA

Agent Vaginal Delivery Cesarean Section

Procaine 40-60 mg. Not rec.

Tetracaine 3-5 mg. 6-8 mg.

Lidocaine 25-50 mg. 75-100

Dibucaine 2.5-4 mg. 4-5 mg.

Modified from Hingson, R. A., and Cull, W. A. 6

CONCLUSIONS

Why is the state of Mississippi below the ex-
pected national maternal mortality rate from
anesthesia? Why were there no mortalities in the
last two years of the study? Lack of reporting
may be a factor but improved care by informed
physicians must also be considered. The Mis-
sissippi State Medical Association and the Mis-
sissippi Academy of General Practice must be
commended for their continuing effort in gradu-
ate medical education for the practitioners of the
state.

2500 North State St. (39216)

Supported in part by NIH General Research Grant
No. 69419.

REFERENCES

1. Webster, A.: Maternal Deaths at the Cook County
Hospital, Am. J. Obst. & Gynec. 191:244, 1968.

2. Bonica, J.: Principles and Practice of Obstetric
Analgesia and Anesthesia, F. A. Davis Co. 1:751,
1967.

3. Eastman, N. and Heilman, L.: Williams Obstetrics,
13th Edition, Appleton, Century and Crofts, p. 472,
1966.

4. Greiss, F. C. and Anderson. S. G.: Elimination of
Maternal Deaths From Anesthesia, Obst. & Gynec.
29:677, 1967.

5. Maternal Mortality Committee Exhibit: Maternal
Mortality in Mississippi, 1957-1966, Annual Meet- .
ing, Mississippi State Medical Association, 1969.

6. Hingson, R. A. and Cull, W. A.: Conduction An-
esthesia and Analgesia in Obstetrics, Clinical Obst.
and Gynec. 4:95, 1961.

7. Asling, J.: Hypotension After Regional Anesthesia,
Current Concepts and Practice of Obstetrical An-
esthesia. Symposium — University of California at
San Francisco, p. 27, April, 1969.

8. Greenhouse, B. S., Hook, R. and Hehre, F. W. :
Aspiration Pneumonia Following Intravenous Ad-
ministration of Alcohol During Labor, J.A.M.A.
210:2393, 1969.

9. Flowers, C. E., Jr.: Obstetric Analgesia and An-
esthesia, Hoeber, p. 154, 1967.

10. Flowers, C. E., Jr.: Current Concepts and Practice
of Obstetrical Anesthesia, University of California
at San Francisco, April, 1969.

JOURNAL MSM A

Seminar on Care of the Newborn— II

Resuscitation of the Newborn

ROSS E. SMITH, M.D., and
ALFRED W. BRANN, JR., M.D.

Jackson, Mississippi

One of the two most common causes of death
in the first day of life is asphyxia. The other
cause, which is intimately related, is prematurity.
In combination, these two causes alone account
for over two-thirds of the deaths in the first week
of life. Time is of the essence to a critically ill
newborn who is attempting to make the transi-
tion from his previous, totally dependent, intra-
uterine state to a totally independent, extrauterine
state. Thus an understanding of some of the fac-
tors leading to fetal and neonatal asphyxia, and a
plan of action for resuscitation of the asphyxiated
infant may be helpful in reducing the neonatal
mortality and the central nervous system mor-
bidity rate from asphyxia.

In the past few years much information has
been gained regarding maternal and fetal physi-
ology, especially as it relates to the influence of
of labor on the fetus and the newborn. This in-
formation. which was recently reviewed by Dr.
M. E. Towell. has been helpful in understanding
some of the mechanisms of fetal and neonatal
asphyxia.1

Throughout a normal gestation up to the be-
ginning of labor, the fetus is in a state of ade-
quate oxygenation and not in a state of hypoxia,
as was previously thought. As normal labor pro-
gresses, a mild hypoxia, hypercarbia, and acidosis
develops. This alteration of the acid base and
blood gas status of the fetus is related to the in-
termittent interruption of adequate perfusion of
the placenta during normal uterine contractions.
It is not difficult to understand how deranged
maternal, placental, or fetal physiology superim-
posed on the normal biochemical asphyxia of la-
bor may significantly reduce the ‘'marginal’’ oxy-
genation of the fetus and produce increasing de-

From the Department of Pediatrics, University of Mis-
sissippi School of Medicine, Jackson. Miss.

grees of asphyxia. Table 1 is a list of common
conditions of the mother, placenta and fetus which
may significantly alter the newborn’s ability to
remain oxygenated and may set the stage for

The most common causes of death in the
first day of life are asphyxia and prematur-
ity. The two are intimately related and to-
gether account for over two-thirds of deaths
in the first week of life. The authors explain
factors leading to fetal and neonatal as-
phyxia and set forth a plan of action for
managing resuscitation of the asphyxiated in-
fant.

fetal or neonatal asphyxia. Although occasionally
the delivery of an unexpected depressed or as-
phyxiated infant occurs, these times should be
few. Thus, long before the actual delivery, many
of the infants who are “at risk” for developing
asphyxia and who may require early delivery and
resuscitation at birth can be identified.

The respiratory, cardiovascular, and biochem-
ical responses during asphyxia and resuscitation
have been well studied in the newborn Rhesus
monkey.2 These responses closely resemble those
seen in the infant who does not breathe at birth.
During the initial phase of experimental asphyxia
in the monkey, there is a period of primary hyper-
pnea lasting 2-3 minutes followed by a period of
primary apnea, lasting approximately one min-
ute. These two periods are then followed by a
prolonged period of rhythmical gasping, at first
very deep, then gradually becoming more shallow
and finally ceasing approximately 8.5 minutes af-
ter the onset of the asphyxia. Following this is the
period of secondary apnea from which the animal
will not recover unless resuscitation is begun.

AUGUST 1970

417

RESUSCITATION / Smith and Brann

During this asphyxia, heart rate and blood pres-
sure fall, leading to ineffective profusion pres-
sures, in approximately four to six minutes after
the onset of the asphyxia. Both the acid-base and
blood gas status of the animal change rapidly.
The oxygen content falls to near 0 in 2.5 min-
utes. The carbon dioxide tension initially is 42
mm/Hg and rises approximately 10 mm/Hg per
minute. The pH is 7.35 initially and during the
early phases of asphyxia falls 0.1 units/minute.
Thus at the end of an 8-10 minute period of
asphyxia the p02 is near 0, pC02 approximately
120 mm/Hg and pH approximately 6.8.

RESPONSE PHASES

These responses closely resemble responses that
can occur in the human fetus subjected to cord
compression from any cause or to the newborn
infant who does not breathe at birth. Frequently,

TABLE 1

CONDITIONS ASSOCIATED WITH
ASPHYXIATION OF INFANTS*

Maternal

Mechanical

Cephalopelvic disproportion
Abnormal uterine contraction
Multiple pregnancy
Prolonged labor
Malposition of infant
Difficult forceps delivery
Abnormal presentations
General
Diabetes
Toxemia

Hemorrhage and hypotension
Oversedation
Cardiorespiratory disease
Severe anemia
Grand multiparity
Juvenile pregnancy
Infection
Placental

Placenta previa
Abruptio placentae
Prolapsed cord
Infarction
Infection
Fetal

Erythroblastosis

Passage of meconium

Fetal bradycardia and tachycardia

Intrauterine infection

Prematurity

* From W. A. Hodson. Hospital Medicine, 1960.

the gasping phase of the asphyxia may occur in
utero. The important aspect of this experimental
data for clinical purposes in resuscitation is the
linear relationship between the duration of as-
phyxia and the recovery of respiratory function
following resuscitation. For every minute, af-
ter the last gasp that resuscitation is delayed, there
will be a two minute delay in onset of gasping
and a four minute delay in the onset of rhythmical
breathing. It can readily be seen that time is of
the essence if the apneic newborn is to be saved
without brain damage. Thus, it is imperative that
all medical personnel in the delivery room and
nursery be extremely familiar with the plan of
action for resuscitation. This includes the constant
availability of needed resuscitation equipment
and oxygen.

EVALUATION OF INFANT AT BIRTH

During the first minute after birth there should
be a routine followed in evaluating every baby.
Immediately on delivery the infant’s head should
be held down and the oropharynx should be suc-
tioned prior to the first breath. After cord clamp,
he should then be placed supine in a warm en-
vironment, with repeated gentle suction of the
oropharynx. Nothing more than light slapping of
the feet should be used in stimulating the infant
to breathe.

By the end of the first minute ausculation of
the heart should be done so that the one minute
Apgar score can be determined. On the basis of the
Apgar score, the need for further resuscitative
measures can be determined. Table 2 is an out-
line of the Apgar scoring system.3 In a large series
of infants, 17,221 under study by the Collabora-
tive Project on Cerebral Palsy, the Apgar scoring
system at one and five minutes was used.4 The
following distribution was seen for the one min-
ute scores; 0-3, 6.7 per cent; 4-6, 14.5 per cent;
7-10, 78.9 per cent. By five minutes, there were
fewer infants with low scores: 0-3, 1.8 per cent;
4-6, 3.5 per cent; 7-10, 94.8 per cent. When the
entire series is broken down by specific birth
weights, a high percentage of infants weighing
1500 grams or less had lower one and five minute
Apgar scores than heavier babies. There was a
positive correlation between neonatal mortality
rates and neurologically abnormal infants at one
year with low five minute Apgar scores.

Although there have been many abuses and
misuses of the Apgar scoring system since its
initial description in 1953, 5 it still remains the
single most rapid and reproducible scoring sys-
tem of the infant’s status in the immediate post-
natal period. In Dr. Apgar’s words,6 “Nine

418

JOURNAL MSMA

TABLE 2

ACRONYM OF THE APGAR SCORE*

Sign

0

Score

1 2

A Appearance (color) Blue; pale

P Pulse (heart rate) ... Absent

G Grimace (reflex irritability response to stimula-
tion of sole of foot by glancing slap) No response

A Activity (muscle tone) Limp

R Respiration (respiratory effort) Absent

Body pink; extremities Completely pink

blue

Below 100 Over 100

Grimace Dry

Some flexion of extrem- Active motion

ities

Slow; irregular Good strong cry

* From Butterfield and Convey, J.A.M.A. 181:353, 1962.

months’ observation of the mother surely war-
rants one minute observation of the baby.”

INITIATION OF RESPIRATION

As mentioned previously, the process of nor-
mal labor and delivery produces a mild biochem-
ical asphyxia. The increasing C02. decreasing pH.
and decreasing oxygen acting on the medullary
respiratory center and the peripheral chemorecep-
tors, play a major role in initiating respiration.
Thermal and tactile stimuli also play a role in
initiating respiration but are thought to be of
secondary importance. In most infants, the first
breath is usually within a few seconds after birth.
During these first few breaths, negative pressures
between 20 and 70 centimeters of water have been
recorded. With these negative pressures, the lungs
rapidly expand and the functional residual ca-
pacity of the newborn lung reaches three-fourths
of its normal value during the first few breaths.

RESUSCITATION

For practical purposes of identifying infants
who may require special resuscitative measures,
the infants are divided into three groups by their
one minute Apgar score: 7-10. 4-6, and 0-3. The
management for each of these groups will be de-
scribed.

A. Infants with Apgar score 7-10

As was seen from the previous study,4 the ma-
jority of newborns had Apgar scores of seven or
greater. These infants should require no more
than gentle oropharyngeal suction with a Delee
trap or a bulb suction.

After the initiation of cry and respirations, the
infant should be dried and wrapped in a warm
blanket to insure maintenance of normal body
temperature. Drops in temperature should be
avoided to prevent the severe consequences of

cold stress, which may be a marked metabolic
acidosis and an increase in oxygen consump-
tion.7’ 8’ 9- 10 This is particularly the case in a
newborn who has had a period of in utero as-
phyxia or is depressed for other reasons. This
infant may have an increased difficulty with
maintenance of his body temperature, especially
in a delivery room with an ambient temperature
of 70°F. Skin temperatures may fall as much
as 0.5°F/minute in this environment.11 This fall
in temperature is obviously accentuated if the wet
newborn is not immediately dried and placed in
a warm environment.

B. Infants with Apgar score 4-6

The largest group of infants requiring some form
of resuscitation have Apgars of 4-6. They are
usually pale or blue and have not established
sustained rhythmic respirations. However, the
heart beat is usually 100 or more. If the infant
does not respond within IV2 minutes after birth
following gentle oropharyngeal suction with the
Delee trap or bulb suction and slapping of the
feet lightly, additional measures should be in-
stituted to prevent further asphyxia. A small plas-
tic oral airway is placed in the mouth. By face
mask, oxygen is delivered under 16 to 20 centi-
meters of water pressure. This is usually sufficient
to expand the lungs and initiate respirations in a
majority of infants in this group.

At this point, the heart rate can be used as
the single best indicator of the success of resus-
citation. If the heart rate picks up above 100,
respirations usually begin. If the heart rate is be-
low 100 and falling, the resuscitative procedure,
outline for infants with a one minute Apgar
score of 0-3, should be immediately instituted.

C. Infants with Apgar score 0-3

These infants are in serious trouble at birth and
should have immediate endotracheal intubation.

AUGUST 1970

419

RESUSCITATION / Smith and Brann

Prior to the onset of positive pressure ventilation
(PPV) the glottic and tracheal regions should be
suctioned, being careful to remove any thick mu-
cus or meconium. Positive pressure ventilation
with 100% Ol> using pressures not to exceed 25
to 35 cm. of water should be instituted. As stated
previously, the length of PPV required is propor-
tional to the length of asphyxia. However, usually
not more than 3-8 minutes of PPV is necessary.
The endotracheal tube should be removed as
soon as rhythmical respirations are sustained.

Cardiac massage is a technique that may be
required in this group of infants whose heart
rate is inaudible or remains below 60 beats per
minute after Vi minute of assisted ventilation.
With the method described under Procedures,
aortic pressures of 60 to 80 per cent of normal
can be obtained. Ventilation must be maintained
during cardiac massage. A ratio of three massages
to one insufflation is ideal.

TABLE 3

EQUIPMENT NECESSARY FOR RESUSCITATION

1. Suction catheter ( #8 infant feeding tube)

2. Mouth or mechanical suction apparatus

3. Plastic infant oropharyngeal airway

4. Infant sized HOPE RESUSCITATOR (1 liter bag)

5. Rubber face mask

6. 02 from wall outlet or portable tank with flow meter

7. Laryngoscope with infant blade (straight) with extra
bulb and batteries

8. Endotracheal tubes (sizes 8, 10, 12)

9. Guide wire for endotracheal tube

10. Syringe and needles

11. Drugs

7.5% sodium bicarbonate
Aqueous adrenalin 1:1000
Dextrose solution 10% and 50%

Nalline®

Fluids and drugs have a valuable role in re-
suscitation and frequently are needed in resusci-
tation in this group of infants. However, it must
be stressed emphatically, there is no substitute
for PPB with 100 per cent oxygen. Without ade-
quate oxygenation of the myocardium and the
respiratory center in the brain stem, fluids and
drugs are ineffective. A list of the useful fluids
and drugs and their dosages are given in Table 3.

1. Sodium Bicarbonate: As previously stated,
with severe asphyxia (Apgar score 0-3), there is
acidosis, bradycardia, hypotension and at times
cardiac arrest. This clinical condition may be pres-

ent at birth or develop in an infant, Apgar score
4-6 who did not respond to the initial resuscita-
tive measures. Thus if the Apgar score remains
three or less after positive pressure ventilation,
IVi per cent sodium bicarbonate (4 cc/kgm) di-
luted with equal amounts of 10 per cent glucose,
should be given through the umbilical vein or
artery catheter. This should be done while con-
tinuing positive pressure ventilation with oxygen
and continuing external cardiac massage. If there
is still no response, half of the initial dose of
sodium bicarbonate should be repeated. Without
the aid of pH determinations continued sodium
bicarbonate should be given with caution.

2. Adrenalin: If after the above measures,
the heart rate is still below 50, 0. 1-0.2 cc. of
aqueous adrenalin 1:1000 diluted in 10 cc. 10 per
cent glucose should be given I.V. No more than
two doses of adrenalin should be used.

3. Dextrose Solution: In severely depressed in-
fants who have not responded to the above mea-
sures, 1-2 cc/kgm of 50 per cent glucose diluted
with equal parts of 10 per cent glucose should
be given through the umbilical vein or artery over
a 3-5 minute period. Glucose solution is given in
the event that hypoglycemia may be contributing
to the clinical picture of severe depression. This
may be the case in infants who show signs of
post-maturity or infants who are low birth weight
for gestational age.

4. Nalorphine HCL USP (Nalline®): The use

of narcotic antagonists does not play a prominent
role in resuscitation. Nalline® 0.1 mgm/kgm di-
luted in 2 cc. of DioW I.V. should only be ad-
ministered to a severely depressed infant whose
mother is clearly known to have had analgesic
administration shortly before delivery. It should
be re-emphasized that drug administration does
not take the place of PPV with oxygen.

5. Blood: There is no substitute for blood
when one has clinical evidence of shock, which
in the newborn as in the older child is manifested
by extreme pallor. This may be suspected when
there has been a history of excessive vaginal
bleeding or multiple births, with one twin trans-
fusing the other. In case of emergency, blood
from the mother can be used, without cross match-
ing, in the amount of 10 cc/kgm infused into
the umbilical vein. If there has been blood loss,
blood should be given to boost the hematocrit to
40 per cent or above.

POSTRESUSCITATION CARE

Any infant who has required positive pressure
by endotracheal tube should be treated as if he
were at greater risk throughout his nursery period

420

JOURNAL MSM A

than a child of an uncomplicated delivery. For the
first 24 hours he should be observed extremely
closely. The nursery staff should be prepared to
reinstitute resuscitative measures at any time.
Care should be taken to maintain the temperature
between 36.5°C and 37.5°C. Oxygen may be
required in the initial hours to reduce the infant’s
cyanosis. However, care should be taken not to
continue oxygen longer than necessary because of
the danger of oxygen toxicity to eye and lung.

Oral fluids should be withheld for the first six
hours. However, parenteral fluids with glucose
and sodium bicarbonate may be necessary to
maintain both a normal blood sugar and acid base
status. The gastric contents should be aspirated,
especially if there has been excessive secretion
or if there was a history of polyhydramnios. Vita-
min K1? 1 mgm I.M., should be given as in all
routine deliveries, to prevent hemorrhagic disease
of the newborn. Cultures of blood, cerebral
spinal fluid, and urine along with a chest film
and antibiotic therapy are indicated when infec-
tion is suspected. Usually infants requiring ex-
tensive resuscitation are started on prophylactic
antibiotics. The antibiotics currently being recom-
mended are aqueous penicillin G, 50,000 units/
kgm/24 hours given in two divided doses I.M. or
I.V.; and, Kanamycin 15 mgm/kgm/24 hours
given in two divided doses I.M.

PROCEDURES

The procedures to be used are:

A. Endotracheal Intubation

With the infant supine, the neck is slightly hyper-
extended keeping the head in line with the body.
Holding the head steady with the right hand, the
laryngoscope is held in the left hand and the
blade is inserted into the right corner of the
mouth and advanced between the tongue and
palate. As advancement is continued, the blade
is gently moved to the midline and over the base
of the tongue to the space between the base of
the tongue and the epiglottis. Slight lateral pres-
sure will move the tongue to the left of the oral
cavity. With slight elevation of the tip of the
blade the epiglottis is lifted to expose the glottis.

The entrance into the larynx will appear as a
small vertical slit bordered posteriorly by the
aryhenoid cartilages. It is important not to over-
extend the neck as this will place excessive ten-
sion on the epiglottis thus facilitating its move-
ment anteriorly. One can often obtain better vis-
ualization of the glottis by applying a counter-
force over the thyroid cartilage with the fifth
finger of the left hand.

After obtaining adequate visualization of the
glottic area, any material such as blood, amniotic
debris or mucus should be gently suctioned out.
The endotracheal tube is then inserted at the
corner of the mouth and the vocal cords until the
“shoulders” of the tube are resting against the
“false cords.” The laryngoscope is then with-
drawn and positive pressure ventilation is begun.

B. External Cardiac Massage

In order to insure maximum benefit from this
procedure, it is necessary to have firm support
beneath the infant’s thorax. This can be provided
by a lightly padded piece of plywood. Allowing
for three to four “puffs” of ventilation to provide
the alveoli with oxygen, the index and middle
fingers of the right hand are placed in the mid-
portion of the sternum just at the left margin.
Enough force is applied to depress the sternum
about one half to three fourths of an inch. The
rate of massage should be about two “beats” per
second or 120 “beats” per minute.

Ventilation and external cardiac massage
should be performed alternately, in the ratio:
three massages for each insufflation. Every five
minutes one should pause long enough to evaluate
the return of adequate cardiac function (heart
rate >100 and increasing strength of heart tones).
External cardiac massage should continue until
adequate cardiac function has returned. Force of
compression may be roughly gauged by palpation
of femoral or carotid pulses.

C. Umbilical Vein/Artery Catheterization

After sterile preparation of the umbilicus, a #5
radiopaque feeding tube, filled with sterile sa-
line, is introduced into the umbilical vein. The
catheter should be inserted approximately 8-10
cm. in infants > 2000 gms, and 6-8 cm. in in-
fants < 2000 gms. A firm but gentle steady pres-
sure usually places the catheter through ductus
venous into the inferior vena cava. Following the
insertion it is advisable to obtain a portable x-ray
of the chest to determine exact location; however,
it is not necessary to wait for the x-ray before
injection of needed medications, fluids or blood in
the delivery room.

If medications are used, the concentration
should be diluted before injection as indicated
under drug therapy. If the catheter has entered
one of the hepatic veins and not advanced
into the inferior vena cava, the injections of hy-
pertonic solutions such as 50 per cent dextrose or
7.5 per cent sodium bicarbonate may cause lo-
calized hepatic necrosis. The authors attach a 3-

AUGUST 1970

421

RESUSCITATION / Smith and Brann

way stopcock to the umbilical catheter to allow
continuous intravenous fluid administration along
with possible intermittent blood sampling, yet still
maintaining a closed system at all times.

The umbilical venous catheter should rest in the
inferior vena cava. If the catheter has been ad-
vanced too far, withdrawal of a few cm. should
be done. However, if the catheter is in one of
the hepatic veins or even if it appears to have
entered the portal vein and not into the inferior
vena cava, it should be withdrawn entirely and
replaced, unless sterile technique has not been
broken, wherein it may be simply readvanced. If
there is any doubt, withdraw the catheter and re-
place it again under a new sterile prep and drape.
Sepsis of the newborn can easily be produced by
a break in the sterile technique of umbilical vein
insertion. The umbilical venous catheter is usual-
ly continued for 12-24 hours after the immediate
period of resuscitation for intravenous fluid ad-
ministration. If the infant is stable and tolerating
p.o. glucose water or formula at the end of this
time, it can safely be discontinued. If the catheter
is left in for longer than 24 hours, many centers
start the infant on prophylactic antibiotics (see
drugs).

The same sterile techniques for umbilical ar-
tery insertion should be followed. The tip of the
catheter should come to rest in the aorta just above
the renal artery. This catheter can be used for
arterial blood sampling for pH, pC02 and p02.
It must be emphasized that difficulties have been
observed in infants following umbilical artery
catheterization.12 The placement of a catheter
in this vessel should be done only if arterial
blood sampling for pH, pC02, and p02 determi-
nation is planned.

MANAGEMENT PLAN

A plan of action for management of the se-
verely depressed newborn is as follows:

( 1 ) Place infant supine under a radiant warm-
er in head down position with a slight lateral
tilt.

(2) Gently suction oropharynx and dry infant.

(3) Insert endotracheal tube.

(4) Establish positive pressure ventilation
through the endotracheal tube with mouth to tube
ventilation.

(5) Cannulate the umbilical vein or artery.

(6) If HR does not increase to 100 beats per
minute after 30 seconds of adequate ventilation,
begin external cardiac massage.

(7) If at the end of three minutes from birth

or approximately \Vi minutes from onset of ade-
quate ventilation and external cardiac massage,
the heart rate is not above 100 beats per min-
ute, a sterile solution of IVi per cent sodium bi-
carbonate (4 cc/kgm) diluted with equal parts of
10 per cent glucose is injected through an umbil-
ical vein catheter.

(8) If the heart rate remains below 50, give
0.1 cc. aqueous adrenalin 1:10,000 concentra-
tion followed by 1-2 cc/kgm of 50 per cent dex-
trose solution diluted with equal parts of 10 per
cent Dextrose through the umbilical catheter.

(9) Adequate ventilation and external cardiac
massage must be continued throughout the entire
time of drug administration until adequate spon-
taneous ventilation and cardiac activity is as-
sumed.

(10) Transfer the infant to the nursery for in-
tensive care.

2500 North State St. (39216)

The authors wish to thank Dr. Donald Sherline from
the Department of Obstetrics and Gynecology for his
helpful comments.

REFERENCES

1. Towell, M. E. : The Influence of Labor on the Fetus
and the Newborn, Ped. Clinics N.A. 13:575-598,
1966.

2. Adamsons, K., Jr., Behrman, R., Dawes, G. S.,
James, L. S., and Koford, C.: Resuscitation by Pos-
itive Pressure Ventilation and Tris-hvdroxymethyl-
aminomethane of Rhesus Monkey Asphyxiated at
Birth, J. Pediat. 65:807, 1964.

3. Butterfield, J., and Covery, M. J.: Practical Epigram
of the Apgar Score, J.A.M.A. 181:353. 1962.

4. Drage, J. S., and Berendes, H.: Apgar Scores and
Outcome of the Newborn, Ped. Clinics N.A. 13:635,
1966.

5. Apgar, V.: A Proposal for a New Method of Evalu-
ation of the Newborn Infant, Anesth. and Anal.
32:260, 1953.

6. Apgar, V.: The Newborn (Apgar) Scoring System,
Ped. Clinics N.A. 13:645, 1966.

7. Oliver, T. K., Jr.: Temperature Regulation and Heat
Production in the Newborn, Ped. Clinics N.A. 22:88.
1966.

8. Gandy, G. M., Adamsons, K., Jr., and Cunningham,
N.: Thermal Environments and the Acid-Base Ho-
meostasis in Human Infants During the First Few
Hours of Life, J. Clin. Invest. 43:751, 1964.

9. Adamsons, K., Jr., Gandy, G. M., and James, L. S.:
The Influence of Thermal Factors LTpon Oxygen
Consumption of the Newborn Human Infant,
J. Pediat. 66:495, 1965.

10. Miller, D. L., and Oliver, T. K., Jr.: Body Tempera-
ture in the Immediate Neonatal Period: The Effect
of Reducing Thermal Losses, Amer. J. Ob.-Gyn.
94:964, 1966.

11. Du, J. H. N., and Oliver, T. K., Jr.; The Baby in
the Delivery Room, a Suitable Microenvironment,
J.A.M.A. 207:1502, 1969.

12. Wigger, H. J., Bransilver, B. R., and Blanc, W. A.:
Thromboses Due to Catheterization in Infants and
Children, J. Pediat. 76:1, 1970.

13. Behrman, R. E., James, L. S., Klaus, M., Nelson, N.,
and Oliver, T. : Treatment of the Asphyxiated New-
born Infant. J. Ped. 74:981, 1969.

422

JOURNAL MSMA

MEETINGS

NATIONAL AND REGIONAL

American Medical Association, Clinical Conven-
tion, Nov. 29-Dec. 2, 1970, Boston. Annual
Convention, June 20-24, 1971, Atlantic City.
Ernest B. Eioward, Executive Vice President,
535 N. Dearborn St., Chicago, 111. 60610.

Southern Medical Association, 64th Annual
Meeting, Nov. 16-19, 1970, Dallas. Mr. Rob-
ert F. Butts, Executive Director, 2601 High-
land Ave., Birmingham, Ala. 35205.

STATE AND LOCAL

Mississippi State Medical Association. 103rd An-
nual Session, May 3-6, 1971, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Mississippi Academy of General Practice, Annual
Assembly, Oct. 20-22, 1970, Biloxi. Miss Lou-
ise Lacey, Executive Secretary, P.O. Box 1435,
Jackson.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday,
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Howard A. Nelson, 308 Fulton
St., Greenwood, Secretary.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-

taurant, Hernando. Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday,
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, February, April, June, August, October,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October. Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell, 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March.
June, September, and December. A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday,
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.
W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m., Old Southern Tea Room, Vicksburg.
Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

AUGUST 1970

423

Radiologic Seminar XCVIII
Duplications of the Renal Pelvis and Ureter

T. S. McCAY, M.D.
Jackson, Mississippi

In the normal course of embryologic develop-
ment a single ureteral bud arises from each wolf-
fian duct. As development progresses, these ure-
teral buds become the right and left ureters. The
cephalic ends of the ureters divide to produce
the renal pelves, calyceal systems, papillary
tubules and collecting tubules. Incomplete double
ureter is formed when the ureteral buds divide
too early or the renal pelvic division extends
into the ureter. Duplications thus produced may
vary from an exaggerated major calyx to the up-

Sponsored by the Mississippi Radiological Society.

From the Department of Radiology, St. Dominic-Jackson
Memorial Flospital.

Figure 1. Ten minute film from an intravenous
pyelogram. Note duplication on the left and small
pelviocalyceal system on the right.

per pole of a kidney to complete division of the
renal pelvis with a divided ureter on the involved
side. In duplications produced by this means,
there will always be junction of the divided ureter
proximal to the urinary bladder. Complete dupli-
cations develop when two separate ureteral buds
arise from a wolffian duct giving rise to two en-
tirely separate ureters with separate pelviocaly-
ceal systems and separate vesical orifices. Either
complete or incomplete duplication may be uni-
lateral or bilateral.

Recognition of duplications of the upper renal
tracts is usually dependent upon pyelography. Oc-
casionally one may suspect duplication on the ba-
sis of elongation of a kidney on the plain radio-

Figure 2. Tomographic study on the same patient
demonstrating large upper pole segment of the right
kidney with no apparent pelviocalyceal system.

424

JOURNAL MSMA

Figure 3. Repeat pyelogram after passage of cal-
culus showing duplication bilaterally .

siderable segment of the upper pole of the right
kidney lying above the pelviocalyceal system.
Figure 3 is from a later study after passage of
the calculus, demonstrating return of function to
the duplicated right upper pole.

In summary, duplications of the renal pelves
and ureters arise from abnormal divisions of the
ureteral buds or from the development of super-
numery ureteral buds. Recognition of duplica-
tions is important since associated anomalies
and associated pathologic conditions are more
frequent than in normally developed excretory
systems. Pyelography is the diagnostic procedure
of choice in demonstrating these anomalies. ***

graph, but pyelography, either intravenous or ret-
rograde, is necessary for confirmation. Sometimes
recognition of duplications by intravenous pye-
lography can be difficult when there is lack of
function of the segment of kidney drained by
the duplicated system. With retrograde pyelogra-
phy, in cases of partial duplication, there may
be obstruction of one of the duplicated ureters
preventing filling. In complete duplications when
all terminal orifices are not recognized and the
connecting ureters opacified, the diagnosis may be
missed. In this connection, it should be mentioned
that frequently there will be an ectopic orifice of
the ureter to the upper pole of the kidney opening
into the vesical neck, the urethra, seminal vesi-
cles, vas deferens, etc. in the male or into the
vesicle neck, urethra, vestibule, vagina, etc. in
the female. In cases where there is failure of
opacification of the duplicated segment of the up-
per renal tract, pyelography will reveal a de-
creased number of renal papillae in the involved
kidney.

Apart from academic interest, recognition of
duplications is of considerable importance. As is
the case with other organ systems with develop-
mental abnormalities, disease states are more
common than in the normally developed. Changes
of obstructive uropathy are common in duplicat-
ed upper pole systems. Due to urine stasis, in-
fections are more common in duplicated drain-
age systems and stones are also frequent. In fe-
males with complete duplication the ectopic up-
per pole ureter will not infrequently open below
the level of the external sphincter giving rise to
urinary incontinence. Ureteroceles are often seen
associated with ectopic ureteral orifices. Also, in
cases of complete obstruction with failure of opac-
ification of the duplicated system, one may be
led to a mistaken diagnosis of tumor involvement
of the involved kidney, the unopacified segment
appearing as a renal mass. Furthermore, it is
conceivable that a renal tumor could be present
in an unopacified duplicated segment and be
missed entirely.

The presented radiographs are those of a man
who presented with right sided renal colic symp-
toms and hematuria. Intravenous pyelography 1.
(Figure 1 ) disclosed a duplicated left upper renal
tract, while on the right the pelviocalyceal sys- ?.
tern appeared significantly smaller than the left,
leading one to suspect duplication on the right
with failure of function of the upper pole. A
tomographic study (Figure 2) revealed a con-

969 Lakeland Drive (39216)

REFERENCES

Emmett, John L.: Clinical Urography. Philadelphia
and London, W. B. Saunders Company, 1964, p.
1010-1040.

Paul. Lester W. and Juhl. John H.: The Essentials of
Roentgen Interpretation. New York and London,
Harper and Row, 1965, p. 512-513.

Brodeur, Armand E.: Radiologic Diagnosis in Infants
and Children. Saint Louis, C. V. Mosby Company,
1965, p. 333-335.

AUGUST 1970

425

MPAC

AMPAC

give you IMPACT, doctor!

But make it a mutual impact, doctor, because your PAC
needs you and you need your PAC. Both AMPAC and
each of the 50 state PAC’s are voluntary, nonprofit, un-
incorporated, autonomous groups whose members are
physicians, their wives, and others in allied professions.
Every group is bipartisan, bound by no party label. The
voting record, platform, and program of a candidate —
not his party — is what the PAC considers.

The basic purpose is twofold: To educate in political
affairs and to provide a means through which the physi-
cian-citizen can effectively make his voice heard in the po-
litical arena. MPAC is medically oriented and medically
directed by a 10 member board consisting of nine physi-
cians and a Woman’s Auxiliary representative.

With the elections behind, MPAC is looking ahead to
1970 when there will be a job to do. Make your voice
count by sending your dues today, $10 for MPAC and
$10 for AMPAC. Better send dues for your wife, too.

MISSISSIPPI MEDICAL
POLITICAL ACTION
COMMITTEE

426

JOURNAL MSM A

Proceedings of the
House of Delegates

102nd Annual Session
May 11-14, 1970
Biloxi, Mississippi

The 67th Annual Session of the House of Dele-
gates was convened during the 102nd Annual
Session of the Mississippi State Medical Associa-
tion, in pursuance to lawful notice given, on May
11, 1970, in the Fountain Terrace of the Hotel
Buena Vista at Biloxi, Mississippi, at 9:12 o’clock
in the morning, by Dr. James L. Royals, Presi-
dent. The invocation was spoken by the Rev. El-
ton Graves, pastor of the First Baptist Church,
Biloxi.

After extending greetings, Dr. Royals present-
ed the Vice Speaker, Dr. John B. Howell, Jr., of
Canton and the Speaker, Dr. William E. Lotter-
hos of Jackson, who assumed the chair. Dr. Wal-
ter H. Simmons, Chairman of the Reference
Committee on Credentials, reported the presence
of a quorum of registered and seated delegates in
accordance with Section 3, Chapter V, By-Laws
of the association.

ANNOUNCEMENT OF REFERENCE

COMMITTEES

Reports of Officers and Board of Trustees
M. Beckett Howorth, Jr., Oxford, Chairman
Thomas G. Barnes, Greenville
William M. Gillespie, Jr., Meridian
William F. Sistrunk, Jackson
E. T. Riemann, Jr., Gulfport
Medical Practices

Joseph B. Rogers, Oxford, Chairman
Louis A. Farber, Jackson
Clyde A. Watkins, Sanatorium
W. B. Howard, Pontotoc
Joseph B. Johnston, Mt. Olive
Miscellaneous Business

C. R. Jenkins, Laurel, Chairman
Ralph L. Brock, McComb
Robert P. Henderson, Jackson
Victor E. Landry, Lucedale
William H. Preston, Jr., Booneville

Credentials

Walter H. Simmons, Jackson, Chairman
Whitman B. Johnson, Clarksdale
Kenneth D. Terrell, Prentiss
Rules and Order of Business

Stanley A. Hill, Corinth, Chairman
Charles P. Bass, Columbia
James E. Alexander, Biloxi

APPOINTMENT OF TELLERS AND
SERGEANTS-AT-ARMS

J. Dan Mitchell, Jackson, Chairman
G. Leroy Howell, Starkville
James M. Dabbs, Waynesboro

REPORT OF THE REFERENCE COMMITTEE
ON RULES AND ORDER OF BUSINESS

To assist the Speaker and Vice Speaker in the
orderly conduct of the proceedings of this House
of Delegates, your Reference Committee on Rules
and Order of Business makes the following rec-
ommendations:

Conduct of Business. Under the By-Laws, the
business of the House must be conducted accord-
ing to Robert’s Rules of Order, Newly Revised,
and the Speaker and Vice Speaker should pre-
scribe the order of business as set out in the By-
Laws. To insure proper recording of the transac-
tions, all delegates recognized should identify
themselves. Except for distinguished visitors and
those having official capacity in the association,
unanimous consent should be obtained for extend-
ing the privilege of the floor to nonmembers of
the House of Delegates. The report of the Refer-
ence Committee on Credentials should constitute
the formal and official roll call of the House.

Reference Committees. The purpose of refer-
ence committees is for affording all members of
the association an opportunity to discuss their
views on matters under consideration by the
House of Delegates.

AUGUST 1970

427

HOUSE OF DELEGATES / Continued

Reports. All reports and resolutions presented
should be referred to the appropriate reference
committee by the chair immediately after their
presentation, the only exception being those which
are of such a nature as to require no further con-
sideration and are, therefore, ready for decision
by vote of this House. Reports published in the
Handbook of the House of Delegates are consid-
ered to have been formally presented and should
be referred to appropriate reference committees
by the chair. Debate should be reserved on all
such presentations until such time as the reference
committees conduct formal hearings and when
they report to the House.

Resolutions. To avoid burdensome tasks upon
the reference committees and to insure that all
members have adequate opportunity to discuss
their views, the House should permit no introduc-
tion of resolutions after the present meeting ex-
cept for ( 1 ) matters of an emergency nature, the
validity of such emergency to be determined by
majority vote, (2) matters relating to a scientific
section of scientific work, and (3) proposed
amendments to the Constitution and/or By-Laws
which would then lie on the table for one year.

The report of the reference committee was
adopted.

ADOPTION OF TRANSACTIONS

On motion by Dr. Lawrence W. Long of Jack-
son, second by Dr. H. C. Ricks, Sr., of Jackson,
the Transactions of the 66th Annual Session of
the House of Delegates, 101st Annual Session of
the Association, May 12-15, 1969, published in
Volume X, Number 8, Journal of the Missis-
sippi State Medical Association, August
1969, were adopted.

REMARKS OF THE SPEAKER

Dr. William E. Lotterhos: In order to main-
tain as much harmony in our House of Delegates
as possible, your Speaker and Vice Speaker are
governed by the majority opinion of the members
of the House. What this majority wants and how
it wants it to be done shall always remain the ulti-
mate determination. However, it is the obligation
of the Speaker to sense this will of the House and
to preside accordingly, and we will hold our rul-
ing ever subject to challenge from a reversal by
the assemblage.

In cognizance with this concept, we are recom-
mending that Robert’s Rules of Order, Newly
Revised be the basis for our parliamentary pro-
cedure, and we would call to your attention that
according to the Constitution and By-Laws of our

state medical association that the up-to-date ver-
sion will be our guide. Thanks to the framers of
this wording, it does not require a constitutional
change in order for us to do this. There are no
rigid codifications of its rules in existence and in
my opinion, parliamentary law serves to aid an
assembly in orderly, expeditious, and equitable
accomplishments of its desires. Any compulsory
adherence to an inflexible set of directives may
thwart rather than abet such an objective.

Once again, this year the Board of Trustees
granted your Speaker and Vice Speaker the op-
portunity to publish the powers and duties of ref-
erence committees, and we trust that you will
find it useful. If you have any comments, con-
structive or otherwise, please feel free to express
yourself to help us keep this an up-to-date docu-
ment. I will invite your attention to the fact that
the reference committees will be the nucleus for
discussion and deliberations on the issues that
will help to set the future policies for our associa-
tion. So, once again we make a plea for you to
attend as many of the reference committees as
you possibly can.

Perhaps the spotlight of this House of Dele-
gates will be focused on our decisions in relation
to the Himler Report. To my knowledge, this is
the first time in the history of organized medicine
that a request has come down from above actual-
ly to seek out the will of the component societies
— to the very “grass roots” if you will. So I hope
that you all have familiarized yourselves with the
contents of this report, both the majority and the
minority recommendations, and I will invite your
attention to the very careful wording of defini-
tions and descriptions. These are important, and
I hope that we can give our delegates to the AMA
some clear-cut decisions that will be carried back
to our national meeting in June of this year,
which is to be held in Chicago.

When it is a policy that has been determined
by this House, our delegates are bound to this on
the first balloting or expression when called upon
to do so, but I think that it is important for you
to know that our representatives do have the
right to change that policy according to the best
way that they see fit. If the one that they are
supporting has been defeated or altered, I am
sure that our delegates will convey to our national
organization your wishes, and I have every confi-
dence in their ability to make wise decisions when
called upon to do so.

Before we get down to business, I would like to
pause for a minute to pay our respects to a great
Speaker, Dr. B. B. O’Mara, who will no longer
be meeting with us in body, but I am sure that

428

JOURNAL MSM A

his spirit will be among us. It is with fond recol-
lection that I have cherished his wise counsel,
and I can still feel the smarting after he had so
ably chastised me when he thought it was appro-
priate. So I am going to take a special privilege
of the chair and recognize Dr. B. B. O'Mara in
memory, and ask that you all stand for a moment
of silent prayer to honor this noble speaker.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

Your reference committee thanks Dr. William
E. Lotterhos, the Speaker of our House of Dele-
gates, and his able colleague Dr. John B. Howell,
Jr. of Canton, the Vice-Speaker, for their fair,
impartial, and efficient conduct of our business in
the House of Delegates. We appreciate his in-
structive remarks and the assistance which he
and Dr. Howell have rendered to all members of
the House and especially to the reference com-
mittees.

We approve the remarks of the Speaker, and
recommend adoption by the House of Delegates.

Applause from the House of Delegates was giv-
en the report of the reference committee on the
Remarks of the Speaker, and the report was
adopted.

PRESENTATION OF DISTINGUISHED GUESTS

The Speaker presented the following distin-
guished guests:

Mr. Doyl Taylor, Chicago, Director, Depart-
ment of Investigation, American Medical Associ-
ation.

Mr. Leon J. Swatzell, Memphis, Assistant Di-
rector, Department of Field Service, American
Medical Association.

Mr. Sam Cameron, Jackson, Assistant Execu-
tive Director, Mississippi Hospital Association.

Mr. Judge Hicks and Mr. John Sanders, stu-
dent delegates, University Medical Center. Jack-
son. Mr. Hicks was accompanied by Mrs. Hicks
who is also a medical student.

Mrs. Gerald D. Dorman, New York, wife of
the President of the American Medical Associa-
tion.

Mrs. James L. Royals, Jackson, wife of the
President of the Mississippi State Medical Asso-
ciation.

ANNOUNCEMENT OF NOMINATING

COMMITTEE

Following a recess for caucuses by association
districts, the Nominating Committee was an-
nounced:

Howard A. Nelson, Greenwood, District 1.

James O. Gilmore, Oxford, District 2.

Arthur E. Brown, Columbus, District 3.

S. Lamar Bailey, Kosciusko, District 4.

James Grant Thompson, Jackson, District 5.

William M. Gillespie, Jr., Meridian, District 6.

C. R. Jenkins, Laurel, District 7.

Sidney O. Graves, Jr., Natchez, District 8.

C. D. Taylor, Jr., Pass Christian, District 9.

Dr. Taylor was elected chairman of the com-
mittee which conducted an open meeting on May
13, 1970, and posted the nominations for the in-
formation of all members.

ADDRESS OF THE PRESIDENT

The Speaker declared the House of Delegates
in open session, and the President, Dr. James L.
Royals, delivered his address. The address has
been published separately in Volume XI, Num-
ber 7, Journal of the Mississippi State Med-
ical Association, July 1970.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

We applaud and commend Dr. James L. Roy-
als, our 1969-70 President, for his service to our
association and for his address to this House of
Delegates. We feel that Dr. Royals has challenged
us to continue to improve the quality and deliv-
ery of medical care in Mississippi.

We invite the attention of the House of Dele-
gates to the final paragraph of his splendid ad-
dress:

“The delivery system is on trial. Our circum-
stances are neither simple nor easy, but the chal-
lenges are great and the gauntlet is down. Let us
do what we must to insure the best medical care
for all Mississippians and for all Americans.”

Your reference committee further invites at-
tention to another poignant quote from Dr. Roy-
als’ address:

“The most tragic hour in American medicine
comes when a physician withdraws himself in
spirit and substance from medical organization.
He renders himself impotent and he chips a stone
from our foundation. The whole is never greater
than the sum of its parts, and no man is an is-
land. His dissent should not be translated into
destruction of his organization, of his colleagues,
or of himself. He simply does not have that right.”

Your committee associates itself in the com-
ment of our speaker when he said that Dr. Roy-
als has honored the office which sought to honor
him.

We approve the address of the President and
ask that it be published in the Journal of the
Mississippi State Medical Association.

In approving unanimously the report of the ref-

AUGUST 1970

429

HOUSE OF DELEGATES / Continued

erence committee, the House of Delegates ac-
corded Dr. Royals a standing ovation.

SPECIAL ADDRESS

Dr. Gerald D. Dorman of New York, President
of the American Medical Association, addressed
the House of Delegates as the principal speaker
of the 102nd Annual Session.

REPORT OF THE DELEGATES TO AMA

Reporting Format. Your Delegates to the
American Medical Association continue to limit
their joint report to this House of Delegates to
key policy actions at the annual and clinical con-
ventions. Because of excellent and detailed re-
porting in the American Medical News and
Journal AMA of scientific and subsidiary activ-
ities, these aspects would only be needless repe-
titions and duplications.

Dr. G. Swink Hicks of Natchez completed his
first full term of two years in 1969 and began
serving his second term to which he was re-elect-
ed in 1969 on Jan. 1, 1970. The senior Delegate,
Dr. Howard A. Nelson of Greenwood, will com-
plete his second full term during the current year.
Our able Alternate Delegates are Drs. Stanley A.
Hill of Corinth and Joseph B. Rogers of Oxford.

The present reporting covers the 118th An-
nual Convention at New York, July 13-17, and
the 23rd Clinical Convention at Denver, Nov.
30-Dec. 3, both 1969. We are grateful for the
attendance, participation, and support at these
meetings of our president. Dr. Royals, and our
president-elect. Dr. Brumby. Many other Missis-
sippi physicians attended and participated in
these conventions, contributing to scientific and
business activities.

New York Annual Convention. The House of
Delegates considered 59 reports and 137 resolu-
tions, meeting in formal session about 16 hours
over four days. Distinguished speakers included
Vice President Agnew and Dr. Roger O. Ege-
berg. Assistant Secretary of HEW for Health and
Scientific Affairs.

Major items of business and policy included
peer review, health care of the poor, medical
care as a matter of right, Medicare and Medicaid,
relations with hospitals, laboratory advertising
and billing, sex education, and internal organi-
zation and finances of AMA.

The House moved decisively on peer review,
encouraging full and complete participation and
implementation at all levels of medical organiza-
tion. The House stated that it “knows of no

greater challenge facing the profession today
than to secure universal acceptance and applica-
tion of the peer review concept. . . The action
made it clear that should medicine fail in meet-
ing this challenge, the task will be done for us
and not on our terms.

In this same connection, the delegates recog-
nized the physician’s influence on the cost of
care, stating that “the doctor has a significant
and responsible role in any organized effort to
control health care expenditures.” With specific
reference to Medicare and Medicaid, the House
took four major actions:

— Expanded peer review at component society
level to reduce hospital and extended care fa-
cility stay and to expand ambulatory care.

— Eradication by the profession of isolated
abuses by physicians.

— Promotion of innovative health service de-
livery systems for low income communities.

— Preservation of care quality in the face of
cost containment measures.

But in the matter of Social Security Adminis-
tration fee freezes, the House said that the set-
ting of “rigid limits on levels of payments to phy-
sicians who provide services appear in contra-
diction to Congressional intent” that these pa-
tients receive care on the same basis as private
patients. A call was made for the Congress to
reassess its intent and priorities in relation to
Title XIX.

The AMA again asked for the identities of
physicians said to have abused Medicare and
Medicaid and condemned the practice of release
by government agencies of gross amount paid to
individuals and groups under the programs with-
out further explanation, giving a frequently false
impression of abuse.

Your Delegates introduced a resolution in re-
sponse to the mandate given us in Resolution
No. 3, subject: JAMA Laboratory Advertising, at
our 101st Annual Session. A number of similar
resolutions were introduced by other states. De-
spite diligent and persistent effort, the House con-
curred with the Judicial Council’s views that the
advertising pages of Journal AMA cannot be de-
nied a lawful activity, including independent lab-
oratories with industrial sponsorship.

The frequently discussed and sometimes mis-
understood position on medical care as a right
was clarified to the extent of a policy statement:

— That it is a basic right of every citizen to
have available to him adequate health care.

— That it is a basic right of every citizen to
have free choice of physician and institutions in
obtaining medical care.

— That the medical profession, using all means

430

JOURNAL MSMA

at its disposal, should endeavor to make good
medical care available to each person.

A preliminary policy on health care of the
poor states that comprehensive services in this
connection are desirable, that it must be a long-
range, continuing program, that research on un-
met needs which is documented should be im-
plemented, that the poor should participate in
planning at community level, and that physicians
should work with organizations in and out of
medicine where concern for care of the poor has
been expressed.

The Scientific Assembly was reorganized with
the several specialty societies having been given
a stronger voice in the affairs of their respective
sections. Each of the 24 scientific sections is to be
governed by a section council whose members
are selected by the appropriate specialty society.
The new format becomes effective Jan. 1, 1972.

By-Laws relating to membership eligibility
were amended to permit qualified osteopaths to
become full, active members. While conceding
that the primary responsibility for family life edu-
cation is in the home, the House “supported in
principle the inauguration by State Boards of
Education or school districts, whichever is appli-
cable, of a voluntary family life and sex educa-
tion program at appropriate grade levels.” The
House supported the integrity of hospital medi-
cal staffs in self-government, having previously
endorsed the concept of voting membership on
hospital governing boards for physicians.

The financial picture for AMA is not bright
with mounting costs, broadened areas of activity,
and about $4 million due in federal income taxes
on advertising. We forsee a dues increase to $100
per year effective in 1971.

At the New York convention, the House of
Delegates took a unique action, electing a num-
ber of senior state medical association and na-
tional specialty society executives to membership
in AMA. Our Executive Secretary, Mr. Row-
land B. Kennedy, was among them.

Denver Clinical Convention. Major actions at
the Denver Clinical Convention included con-
clusive actions on health care of the poor, long-
range planning for AMA, discontinuation of the
AMA-ERF Institute for Biomedical Research, a
statement of policy on marijuana, private prac-
tice, governmental delivery programs, and costs
of medical care. The House of Delegates acted
on 99 items of business among which were 33 re-
ports and 66 resolutions.

In taking definitive actions on health care of
the poor, the House reaffirmed its policy on medi-
cal care as a basic right, calling for increased
funding of effective government programs, proj-

ects to eliminate unfavorable environmental con-
ditions, increased physician services in the urban
slums, expansion of health careers by recruitment
from disadvantaged areas, better prenatal and
postnatal care, family planning services, a crack-
down on quackery which exploits the poor, im-
proved mental health services programs, and
more participation in AMA activities by minority
group physicians.

The Report of the Committee on Planning and
Development for AMA (Himler Report) was re-
ceived formally by the House of Delegates. In-
stead of generating the anticipated controversy,
the report was discussed and handled with lit-
tle fanfare. The House established an ad hoc
committee to receive the report, to recommend
methodology for a permanent committee, and to
send the report to state associations requesting
resolutions for consideration at the 1970 annual
convention.

After years of discussion and debate, the
House of Delegates adopted as policy that “can-
nabis (marijuana) is a dangerous drug and as
such is a public health concern. It is a psycho-
active substance which can have a marked del-
eterious effect on individual performance and
social productivity. A significant number of ex-
posed persons become chronic users with con-
comitant medical and interpersonal problems.”

The House stated that the sale of marijuana
should not be legalized, saying that if potency
were legally controlled, predictably there would
be an illicit market for the more powerful forms.

The AMA-ERF Institute for Biomedical Re-
search, called a noble experiment, was discon-
tinued because of high costs. The House could
find no way to construct a permanent building
for the Institute, and there were no outside funds
available to assist AMA in supporting the multi-
million dollar activity.

The House created a Committee on Private
Practice, assigning it to the Council on Medical
Service. A proposal to establish a new Council on
Private Practice was not favorably considered.
Support for the Regional Medical Programs un-
der PL 89-239 was reaffirmed, but the delegates
opposed on-site auditing of physicians’ accounts
in their offices by government representatives.
Federal licensure was opposed, but state associa-
tions were urged to work with legislatures to
strengthen licensure laws. Physicians were asked
again to be mindful of care costs, as concern was
expressed over the ever-increasing costs of hos-
pital care. The Medicredit concept for voluntary
national health insurance was endorsed.

State medical associations were encouraged to
make active membership available to residents

AUGUST 1970

431

HOUSE OF DELEGATES / Continued

and interns (a benefit available in Mississippi),
and dialogue with medical students was recom-
mended.

Expression of Delegates. Your AMA Delegates
express their appreciation to our own House of
Delegates, to the Board of Trustees, and to the
general officers for support and the mainte-
nance of continuing communication. We sit with
the Board at all meetings and are thereby en-
abled to be fully informed on all policy develop-
ments and positions. We pledge our best effort
in representing your wishes, desires, and policies
in the AMA House of Delegates.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

Drs. Howard A. Nelson of Greenwood and
G. Swink Hicks of Natchez have provided us with
a concise and informative report of the two con-
ventions of the American Medical Association at
which they represented us during 1969. We ap-
preciate the work of our delegates and their ser-
vice to the association and recommend adoption
of their report.

The Speaker invited attention to the portion of
the report pointing out that Mr. Rowland B. Ken-
nedy, the Executive Secretary, had been elected
an Affiliate Member of the American Medical
Association by its House of Delegates during the
1969 New York annual Convention. The report
of the reference committee was adopted.

REPORT OF THE COUNCIL ON
CONSTITUTION AND BY-LAWS

101st Annual Session. At the 1969 annual ses-
sion, the House of Delegates approved two
amendments to the By-Laws of the association,
both with reference to committees.

Section 2, Chapter IX, was amended to ac-
cord constitutional status to the Committee on
Blood and Blood Banking as a permanent com-
mittee of the Council on Medical Service. This
action did not, however, confer a vote in the
House of Delegates on the committee members,
since only elected officers, Trustees, and council
members have the vote.

Section 2, Chapter VI, was repealed as regards
a new nominating procedure instituted in 1968.
The traditional method of making nominations
was restored and will be followed during the
present annual session.

Two proposed amendments to the By-Laws at
the 1969 annual session failed. One was to make

the Speaker and Vice Speaker of the House of
Delegates ex officio members of the Board of i
Trustees without vote and the other would have
empowered the Speaker and Vice Speaker to ap-
point reference committees.

102nd Annual Session. There are no pending
amendments to the Constitution or By-Laws lying
on the table. The council will stand in readiness
to consider any amendments which are proposed
at the present annual session.

The report of the council was received for in-
formation.

REPORT OF THE COUNCIL ON
SCIENTIFIC ASSEMBLY

Organization and Duties. The Council on Sci-
entific Assembly is a constitutional body of the
House of Delegates, charged with the responsi-
bility of planning the annual session of the as-
sociation to include all scientific activities, the
programming, and the scheduling of the annual
session events. The council membership consists
of the chairmen and secretaries of the seven sci-
entific sections and the secretary-treasurer, a to-
tal of 15 members.

102nd Annual Session. Your council began
plans for the 102nd Annual Session in August
1969. The general format, previously ap-
proved by the House of Delegates, has been con-
tinued with general sessions centering around
broad areas of specialty interests. To the maxi-
mum possible extent, conflicts in programming
have been eliminated. The council, in many in-
stances, has requested and placed essayists be-
fore sections from the various specialty societies
not represented in the Scientific Assembly. The
membership is thereby given the benefit of the
presence of these speakers which might not oth-
erwise be available. The specialty societies con-
tinue to work closely in these and other con-
nections to improve the quality and to enhance
the attractiveness of our programs.

At the present annual session, about 12 spe-
cialty groups, four medical alumni groups, and
various nonscientific but medically related bodies
will meet concurrently during May 11-14. We
believe that this arrangement offers variety and
combinations of benefits for the membership in
attendance.

We have scheduled film programs again im-
mediately before each scientific section. We are
gratified with the promising quality and interest
of our scientific exhibits, and we urge each mem-
ber and guest in attendance to avail themselves
of the benefits of the Technical Exhibit which
largely supports our annual session’s scientific
work.

432

JOURNAL MSMA

Expression of the Council. Your Council on
Scientific Assembly is deeply grateful for the
support, cooperation, and assistance we have re-
ceived in planning the 102nd Annual Session.
We are especially aware of the problems con-
fronting our headquarters hotel complex result-
ing from the devastating experience of Hurricane
Camille. The Buena Vista organization has done
splendidly in restoring services and facilities to
fulfill our contract, and we will look forward to
future annual sessions scheduled for our Gulf
Coast.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

We approve the Report of the Council on Sci-
entific Assembly and commend Dr. Simmons and
his colleagues, the seven section chairmen and
secretaries, who prepared for us such an excel-
lent scientific program.

The report of the reference committee was
adopted.

REPORT OF THE JUDICIAL COUNCIL

Constitutional Responsibilities. Your Judicial
Council is one of eight elected councils of the as-
sociation and one of the three which reports di-
rectly to the House of Delegates. Under author-
ities contained in Section 4, Chapter IX, of the
By-Laws, the council is charged with the exer-
cise of the judicial powers of the association and
the interpretation and application of the Prin-
ciples of Medical Ethics of the American Medi-
cal Association. The rulings of the council are
subject to the will of the House of Delegates, and
its judicial decisions may be appealed to the Ju-
dicial Council of the American Medical Associa-
tion.

In the exercise of these powers and discharge
of its responsibilities, the council endeavors to
work with general officers, the Board of Trustees,
and component medical societies. At all times,
the council endeavors to be responsive to the
needs and requests of members of the associa-
tion.

Medical Ethics. At the 101st Annual Session
in 1969, your council reported seven opinions to
the House of Delegates relating to telephone di-
rectory listings, compulsory assessments upon
hospital staff members, transplantation of human
tissue, drugs and devices, treatment of obesity
(condemnation of the so-called “rainbow pill”
regimen), laboratory services, and use of bank
credit cards for payment of physicians’ fees.
Your council reaffirms these opinions.

Two physicians who are members of the asso-
ciation asked the council during the 1969-70 as-

sociation year to examine into a circumstance in
which it was charged that a third physician, also
a member who practiced in the same medical
community, occupied offices in a community
(Hill-Burton) hospital. The council, acting
through the chairman, requested the component
medical society to investigate the charge to de-
termine if sufficient basis existed for formal ac-
tion.

A committee of the component society, in-
cluding the district Trustee, conducted the inves-
tigation and found that the office in question was
merely in close proximity to the hospital with a
walkway. The society expressed the opinion that
no violation of law, regulations, or medical eth-
ics had occurred, and the council has considered
the matter closed. The Board of Trustees also
received a report in this connection through the
Trustee, also at the request of the council.

The council, acting on prior policies of the as-
sociation, issues the following opinion:

Physicians should not maintain offices for the
conduct of their regular private practice for care
of outpatients in community, county, nonprofit, or
church-affiliated hospitals. Exceptions are made
in the case of those physicians whose practice of
medicine is usually conducted in the hospital en-
vironment such as pathologists and radiologists.
The proscription does not apply to the private
proprietary hospital or to physician-owners when
the medical staff approves the practice.

Discipline. The council has conducted no for-
mal proceedings as to disciplinary matters either
by original jurisdiction or on appeal during the
association year. We stand ready, however, to
respond to any need where and when necessary.

AM A Judicial Council. All opinions and de-
cisions of the AM A Judicial Council are regular-
ly reviewed, and each member of your council
maintains a compendium of these opinions and
decisions which are secured and distributed
through our association’s executive office.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

Your reference committee considered the Re-
port of the Judicial Council, noting especially the
opinion of the council with reference to physicians
having offices in hospitals. We concur in this opin-
ion and recommend adoption of the report.

Dr. Tom H. Mitchell of Vicksburg moved to
amend the Report of the Judicial Council by de-
leting the period at the end of the first sentence
in the opinion, replacing it with a comma, and
adding the words “but this shall not exclude the
establishment of such offices as may be necessary
for training under the American Board of Family

43 3

AUGUST 1970

HOUSE OF DELEGATES / Continued

Practice or such other residencies as may be so
structured.” The motion to amend was seconded
by Dr. S. S. Kety of Picayune. The Speaker put
the motion to amend which was adopted, and the
main motion of the reference committee to adopt
the report was passed as amended.

REPORT OF THE COUNCIL ON
MEDICAL SERVICE

Organization and Duties. The Council on
Medical Service is a constitutional body of the
House of Delegates. It is charged with the re-
sponsibility of ascertaining and studying all as-
pects of medical care in Mississippi. Under the
council’s jurisdiction are assigned activities of the
association in medical service, emergency ser-
vice programs, medical care for the indigent, and
the work of allied medical agencies. The council
is assisted in its work by four constitutional and
three ad hoc committees. Programs, studies, and
activities of the several committees embraced a
wide range of subject areas and policy develop-
ment and implementation during the 1969-70 as-
sociation year.

Committee on Maternal and Child Care. The
committee continues to pursue its study of ma-
ternal deaths in Mississippi, and during the year,
it marked a full decade of these studies. The data
have been processed on the association System/
360 computer, and selected papers from the
studies have been published in the Journal. At
the 101st Annual Session, the committee present-
ed a scientific exhibit on its work.

Of particular interest is a recent substudy of
anesthesia-related deaths in the series, and this is
being presented in the Scientific Assembly at your
102nd Annual Session. The committee works
closely with the Department of Obstetrics and
Gynecology of the University Medical Center.

The committee continues to make available
sets of “Maternal Health Desk Cards” which are
distributed to hospitals through chiefs-of-staff and
chiefs of ob-gyn services. The committee con-
ducts regular quarterly meetings to pursue its
duties and review case studies. The chairman is
Dr. William B. Wiener of Jackson, and the com-
mittee has seven members and three consultants
in medicine, pathology, and anesthesiology.

Committee on Mental Health. Continuing its
work in broad areas of mental health, the com-
mittee has been acutely aware of problems in
drug addiction. During the year, it has conduct-
ed educational activities in this connection and
made materials available to physicians who have
addressed school, youth, and other nonmedical
audiences on the subject.

The committee reports that seven of the nine
multi-county regions in Mississippi now have
mental health centers or are preparing to become
operational in the near future. Centers are al-
ready open at Tupelo, the first in the state, and
at Oxford. Units for Jackson and Greenville are
under construction, and plans are in advanced
stages for centers at Meridian, Clarksdale, and
Gulfport. The program has grants totaling $3.7
million.

The chairman is Dr. John J. Head of Whit-
field, and the committee has seven members.

Committee on Occupational Health. The com-
mittee, charged with study of all aspects of oc-
cupational health, continues to pursue an inter-
est of a suitable and adequate legal base for
Workmen’s Compensation in Mississippi. The
1968 amendments covered occupational disease.
Additional measures were pending before the
1970 Regular Session at the time of preparation
of this report.

The committee continues to have interest in
publishing papers in this area of interest in the
Journal.

The chairman is Dr. George D. Purvis of Jack-
son, and the committee has seven members.

Committee on Blood and Blood Banking. This
committee was accorded constitutional status by
the House of Delegates at the 101st Annual Ses-
sion in 1969. It has been active in conducting
Congressional liaison in connection with National
Blood Donors Week and in the issue of a com-
memorative postage stamp on blood donors in a
cooperative effort to focus attention on this acute
need.

The committee has further pursued studies on
computer-based blood bank inventory informa-
tion systems and intends to institute, at the ear-
liest practicable time, a pilot project making use
of the association’s computer. Modest financing
will be required, and the possibilities of secur-
ing this from participating medical institutions
will be explored prior to requesting support funds.
The committee has also considered the possibil-
ity of a grant application for a demonstration
project. When and if such a decision is reached,
the matter will be subject to the usual approval
procedures traditionally followed.

The chairman is Dr. Kenneth M. Heard of
Jackson, and the committee has seven members.

Committee on Nursing (ad hoc). The commit-
tee has been intensely devoted to the major is-
sue of mandatory licensure for nurses in Missis-
sippi during the year. At the 101st Annual Ses-
sion, the House of Delegates received majority
and minority reports from the reference commit-
tee considering this matter. Neither was approved

434

JOURNAL MSM A

nor rejected, and the matter was recommitted to
your council by the House of Delegates.

The association was then confronted with a
difficult dilemma: The 1970 Regular Session of
the Legislature, before which the issue of man-
datory licensure for nurses was to be brought, was
to convene the first week of January 1970, and
with great interests in patient care at stake, we
had urgent need for policy clarification. Useful
debate at the 101st Annual Session, valid opin-
ion, and response from delegates were carefully
noted by the committee and council. Your coun-
cil re-assigned this matter to the committee which
conducted meetings both with nurse organization
representatives and those of the hospital associa-
tion. Extensive deliberation in executive session
was carried out.

The committee reported to your council which,
in turn, conducted a special meeting for consid-
eration of the issue. Taking note of the fact that
nurses have mandatory licensure in 42 of the 51
United States jurisdictions and the fact that nine
of 13 health service and health-related profes-
sions in Mississippi have mandatory licensure,
the committee viewed the problem in the con-
text of discussions before our House of Dele-
gates in 1969. Two points were primary:

— Whether mandatory licensure would serve
as an incentive for improvement in quality edu-
cation toward the end of better bedside nursing.

— Whether mandatory licensure would exacer-
bate the already-critical shortage of nurses.

The committee and your council were deeply
concerned over any threat to ( 1 ) medical as-
sistants to physicians who might not qualify for
licensure and (2) those employed in hospitals
who, while not carrying responsibilities of a
nurse in the literal sense, might be brought un-
der the law and be unable to qualify.

Accordingly, the following policy position was
recommended and approved by the council:

(1) The association supports mandatory licen-
sure of nurses in principle, reserving the preroga-
tive of making further changes and improvement
(in the proposal), including the offering of
amendments to any bill introduced, and further
reserving to the Board of Trustees the prerogative
of final approval of any bill presented.

(2) The Committee on Nursing be utilized in
consultation and testimony before the Legislature
(within the framework of policy established) be-
cause of the committee’s familiarity and expertise
in the matter.

The Board of Trustees considered the work of
the committee and the recommendations of your
council in December 1969 and approved the pol-
icy. The committee chairman appeared as our

witness during hearings on the bill in the 1970
Regular Session. As this report is submitted, the
proposal is still pending, and the association con-
tinues to pursue its goals within the policy frame-
work established.

The chairman of the committee is Dr. Tom H.
Mitchell of Vicksburg, and there are five mem-
bers.

Health Insurance Benefits Advisory Commit-
tee (ad hoc). This committee continues to serve
as the official medical advisory committee for op-
eration of Medicare in Mississippi with official
status before the Certifying Unit for inpatient fa-
cilities, an activity of the State Board of Health.

The committee conducts meetings with physi-
cians experiencing problems under the program,
the Part 1-B carrier, the Part 1-A intermediary, in-
termediaries representing extended care facilities,
the Bureau of Health Insurance of the Social Se-
curity Administration, representatives of HEW,
and providers of services. The committee is not
encouraged over these conferences as to results
of its work and recommendations, despite its
sincere efforts and diligence.

An advisory panel of knowledgeable physicians
was appointed to work in utilization review as
regards hospitals and ECF’s, primarily with ref-
erence to the Certifying Unit, our third ad hoc
body.

The chairman of the committee is Dr. Mai S.
Riddell, Jr., of Winona, and there are seven mem-
bers.

Other Council Activities. Some small but en-
couraging progress is being made in placing prac-
ticing physicians as voting members of hospital
governing boards, despite opposition to this by
many hospitals. This useful and important means
of liaison with the medical staff bears the en-
dorsement of the Joint Commission on Accredi-
tation of Hospitals, the American Medical Asso-
ciation, the American College of Surgeons and
most major national specialty societies, our own
state medical association and most of our sister
state medical associations.

We continue educational efforts and programs
designed to upgrade emergency medical ser-
vice. During the year, the helicopter demonstra-
tion project has shown great promise, as report-
ed in the Journal. Staffing of hospital emer-
gency rooms with physicians has greatly extend-
ed these services, and we endorse the various
approved postgraduate and continuing education
programs for physicians, nurses, and other allied
professional personnel in this area as being vital to
improvement of emergency medical services.
There is a salutary trend in legislative develop-

AUGUST 1970

435

HOUSE OF DELEGATES / Continued

ment on standards for ambulance and driver
standards.

We met prior to the implementation of Title
XIX Medicaid with state officials of the Medicaid
Commission, and we have carefully monitored
program development. Oversight of program de-
velopment remained a primary responsibility of
the Board of Trustees during the year, because
of the Extraordinary Session of the Legislature to
shape the program. Your council, however, is
prepared to assume oversight of the ongoing pro-
gram when and if the Board and House of Dele-
gates so direct, as was the case in Medicare.

The council expresses appreciation to its sev-
eral committees, some of which are among the
most active bodies of the association, and to our
colleagues of the Board of Trustees who have
worked closely with us, giving understanding sup-
port and guidance to our problems and programs.
The council emphasizes to the House of Dele-
gates that its area of responsibility and concern,
the actual practice of medicine and delivery of
care, must have support from all members and
adequate staff in our Executive Office. We re-
pledge our best efforts in carrying out our work.

REPORT OF THE REFERENCE COMMITTEE
ON MEDICAL PRACTICES

We commend the council for its work in our
behalf and for its varied and versatile program
which includes the work of four constitutional
committees — Mental Health, Maternal and Child
Care, Occupational Health, and Blood and Blood
Banking.

We approve the Report of the Council on Med-
ical Service and recommend its adoption.

The report of the reference committee was
adopted.

REPORT OF THE BOARD OF TRUSTEES

Organization and Duties. The Board of Trust-
ees is the executive and governing body of the
association during vacation of the House of Dele-
gates. It is additionally charged with the duties
and responsibilities prescribed by law for direc-
tors of corporations. In the discharge of these
duties, the Board shall have conducted six meet-
ings since the 101st Annual Session. The Board
met in May, September (having been forced to
cancel a scheduled August meeting because of
Hurricane Camille), December, and February.
Meetings are scheduled for April and May. Al-
together, these meetings included 10 meeting
days, usually exclusive of travel time.

Seven officers sit with the Board of Trustees
in all meetings. They are the president, presi-

dent-elect, secretary-treasurer, speaker, vice
speaker, and AMA delegates. The Board is as-
sisted in its work by support of the executive
staff. All 1969-70 meetings were conducted at
our headquarters building at Jackson.

This annual report includes actions on matters
referred to the Board by the House of Delegates
and those items relating to management and pol-
icy functions which are among the Board’s re-
sponsibilities.

Referrals from the House of Delegates. Mat-
ters referred to the Board of Trustees by the
House of Delegates at the 101st Annual Ses-
sion and actions by the House requiring Board
action include:

(a) Blue Cross Group. The new hospital ser-
vice contract available to the membership has
been operational for a year. It provides for 100
days per confinement with a room allowance of
$20 per day and all ancillary services. The House
of Delegates voted to have the Board ask the
plan to pay benefits due 15 subscribers in an
amount of about $16,000 carved out under
Medicare prior to concluding a nonduplication
agreement and to refer the matter of the non-
duplication agreement back to the Board for fur-
ther study.

The Board acted on the mandate of the House
on the payback, and the plan reports that this
has been accomplished. The matter of the non-
duplication agreement has become moot, since
the new 122X contract contains a standard pro-
vision on this.

(b) Resolution No. 2. This resolution asks
that the association “seek amendments to exist-
ing law to provide for more proper and adequate
professional compensation” for autopsy. In ap-
proving the resolution, the House asked “that
the Board of Trustees of the association work out
a suitable fee schedule with the executive com-
mittee of the Mississippi Association of Patholo-
gists.” At the time of preparation of this report,
two bills to accomplish this are pending before
the 1970 Regular Session of the Legislature.

One measure would increase the fee from $75
to $250. While we sponsor and support the bill,
we have asked that the amendment provide for
payment of the usual and customary fee rather
than for a fixed amount. Prior to the convening
of the Legislature, conference was conducted
with the secretary of the Mississippi Association
of Pathologists, and a formal letter in this con-
nection was written inviting recommendations and
suggestions.

(c) Resolution No. 3. This resolution ex-
presses the belief of the association that “to re-
place physician-to-physician consultation with

436

JOURNAL MSM A

physician-to-industrial firm consultation (in the
matter of laboratory services) would be unwise
and not in keeping with good medical practices.”

The resolution also asked that we communicate
our concern over advertisements (for commercial
or industrial laboratories) which appear in Jour-
nal AMA to the AMA House of Delegates. Drs.
Nelson and Hicks introduced an appropriate res-
olution at the 118th Annual Convention of
AMA at New York. There were 10 similar reso-
lutions also introduced.

The AMA House, however, adopted a sub-
stitute resolution and a report of the Judicial
Council which, although reaffirming its historic
position on the practice of pathology being the
practice of medicine in every sense, took notice
of the court decree in the matter of United States
of America v. American College of Pathologists.
Under this position, nonmedical laboratory ad-
vertising is not barred from Journal AMA.

The Board of Trustees invites the attention of
the House of Delegates to the fact that nonmedi-
cal laboratory advertising is not accepted in our
Journal in the light of action at our 1969 an-
nual session.

(d) Resolution No. 4. This resolution asks
that the Mississippi Medical Political Action
Committee prepare educational material concern-
ing the coronership and supply physician-candi-
dates suitable material, coordination, and exper-
tise and that MPAC study the counties of the
state, encouraging physicians to seek this office.

The Board conferred with the chairman of
MPAC and found that funds of the organization
are extremely restricted. Moreover, these are the
only funds which may lawfully be used in can-
didate support. The PAC is not a formal orga-
nization in the sense of being able to sustain ser-
vice programs and studies. The Board, therefore,
offered the best resources available in accom-
plishing this purpose, the pages of our Journal,
and asked the sponsor of the resolution to sub-
mit materials for publication in furtherance of
the objectives which he sought in the resolution.

(e) Resolution No. 6. For the first time, in
1969 the House of Delegates approved the con-
cept of professional corporations for physicians.
This resolution called for our sponsoring an
amendment to Mississippi law in this connection.
An association-sponsored bill was introduced
early in the Regular Session, and we testified
three times in its support before the House Com-
mittee on the Judiciary. The measure passed the
House of Representatives without a dissenting
vote and is pending before the Senate Judiciary
Committee “A” at the time of preparation of
this report.

Nominations to State Board of Health. Follow-
ing up on House actions in 1969, nominations
were made to the Governor for appointment of
three members of the Mississippi State Board of
Health. These are:

For Public Health District 2: Drs. G. Lacey
Biles, Sumner; Julian C. Bramlett, Oxford; and
John R. Lovelace, Batesville.

For Public Health District 4: Drs. S. Lamar
Bailey, Kosciusko; Thomas N. Braddock, West
Point; and Lester D. Webb, Calhoun City.

For Public Health District 5: Drs. Lamar Ar-
rington, Meridian; John R. Laird, Union; and
Omar Simmons, Newton.

CHAMPUS. The association is in its 14th
year as fiscal administrator for the Civilian
Health and Medical Program of the Uniformed
Services (CHAMPUS), the original military Med-
icare. With amendments to the law providing out-
patient benefits and inclusion of retirees, the pro-
gram has grown fourfold into a multimillion dol-
lar operation. It remains unique in these re-
spects:

— It is the only medical care program in Mis-
sissippi operated exclusively under physician con-
trol.

— It is the only medical care plan with a vir-
tually unrestricted prescription drug program.

— It is unique in possessing a true usual and
customary fee reimbursement system under med-
ical peer control.

A five-member review committee meets 12 to
15 times annually on claims in question, and we
are paying about 94 out of every 100 claims ex-
actly as received. Our reorganized Department
of Medical Care Plans in our offices makes pay-
ment weekly to physicians and others providing
services.

Journal MSMA. Our Journal completed
its first decade of service to the association with
publication of the 120th consecutive monthly is-
sue in December 1969. This largest single asso-
ciation-sponsored project is a team effort among
the Editors, Committee on Publications, our
printers, and executive staff. The Board ex-
presses appreciation to the Editors and commit-
tee for their faithful and diligent services and
pledges continued support to this vital member-
ship service.

Legal Matter. At the 101st Annual Session, it
was reported that the association and the Execu-
tive Secretary had been named defendants in the
matter styled /. P. Culpepper, Jr., v. American
Medical Association. Also named as defendants
were the South Mississippi Medical Society and
two officers. AMA dues in transit through the
Mississippi State Medical Association in the

AUGUST 1970

437

HOUSE OF DELEGATES / Continued

amount of about $31,000 were attached by the
plaintiff.

On June 9, the Executive Secretary answered
subpoenas for the association and himself in the
company of our legal counsel in Chancery Court
for Forrest County, when a continuance was or-
dered.

On July 8, the Chancellor, having accepted a
compromise which was also accepted by the plain-
tiff, dismissed the suit with full prejudice as Cause
No. 26509 on motion by plaintiff. AMA dues
funds in the hands of the “garnishee defendant,”
as the association was identified, were thereby
released. Because of the nature of the court or-
der, the matter is closed.

Insurance Programs. In addition to the Blue
Cross hospital group, the association also spon-
sors general accident, disability, health, and life
programs with the Continental Casualty Co.
through Thomas Yates and Co. of Jackson, ad-
ministrators, and a professional liability program
through the St. Paul Companies.

(a) Continental Programs. The group life pro-
gram, one of the most recently initiated, has been
successful to the point that benefits have been
increased by 20 per cent without change in pre-
mium. Where a member carries the previous
maximum of $40,000, he now has $48,000 for
the same premium. We have recently inaugurat-
ed a group ordinary life program which requires
no medical examination.

Participation continues to be excellent in the
disability income programs, catastrophic hospital
expense program, and office overhead expense
group. Approximately 40 per cent of the mem-
bership carry some 1,200 contracts in these pro-
grams. The administrator makes a full disclosure
reporting to the Board of Trustees on all aspects
of these programs. The association does not han-
dle any premiums or benefit payments, nor does
it realize any income from any insurance pro-
gram. We take the position that any profits which
might thereby accrue should be passed along to
participating members in the form of lower pre-
miums, increased benefits, or both.

(b) St. Paul Program. The association is in its
9th year with the St. Paul professional liability
program in which about 600 members partici-
pate. We have enjoyed the lowest professional
liability premium rate in the United States as a
result of our carefully managed program and
claims review counseling by the Board.

The professional liability crisis has become
acute in many states with astronomical premiums

438

ranging up to as much as $20,000 per year for
certain specialties. The Board urges that care and
diligence in the securing of this coverage be ex-
ercised and that threatened or instituted litiga-
tion be brought before the Board by any mem-
ber concerned. The frequency of suits has in-
creased as have awards and settlements in Mis-
sissippi.

Appointments. Under the provisions of Sec-
tion 1, Chapter VII, of the By-Laws, the ap-
pointive powers are vested in the President. Dur-
ing the 1969-70 association year, President
Royals has made the following appointments,
each of which has the endorsement of the Board
of Trustees:

(a) Alternate Delegate to AMA. Following
the death of Dr. B. B. O’Mara of Biloxi, his un-
expired term as Alternate Delegate to AMA was
filled by Dr. Joseph B. Rogers of Oxford, AMA
Alternate Delegate-elect.

(b) RMP Representative. President Royals,
upon assuming office, resigned as the association’s
member of the Regional Medical Program Ad-
visory Council. He appointed as his successor
Dr. C. D. Taylor, Jr., of Pass Christian, our im-
mediate past chairman of the Board of Trustees.

(c) Committee on Publications. This commit-
tee consists of the three Editors and three who
are appointed for terms of three years each by
the Board of Trustess. To serve the unexpired
term of the late Dr. B. B. O’Mara, President
Royals appointed Dr. Frank L. Butler, Jr., of
McComb.

(d) Delta-HEW Project. This program for a
five-county area, since identified as the County
Health Improvement Program (CHIP), is op-
erated by a Committee of Nine consisting of rep-
resentatives of the state medical association, the
State Board of Health, the University Medical
Center, the Mississippi Medical and Surgical As-
sociation, and consumer representatives. Dr.
Temple Ainsworth of Jackson, who represented
the association on the committee for two years,
resigned, and President Royals appointed Dr.
Lyne S. Gamble of Greenville as successor.

(e) Hospital Manpower Study. The Mississippi
Hospital Association received an RMP grant
with which to fund a manpower study. Dr. War-
ren N. Bell of Jackson was named to represent
the association as a member of the advisory body
to the project.

(f) Section on Preventive Medicine. When
Dr. Frank K. Tatum of Tupelo retired from the
practice of preventive medicine, he also resigned
as secretary of the Section on Preventive Medi-
cine of the Scientific Assembly. President Royals,
after consultation with the section chairman, ap-

JOURNAL MSMA

pointed Dr. Frank M. Wiygul, Jr., to serve the
unexpired term as secretary of the section.

(g) Medicaid Committee. Upon invitation by
the Mississippi Medicaid Commission, President
Royals appointed a five-member Technical Ad-
visory Committee on Physicians Services. Mem-
bers are Drs. Joe S. Covington of Meridian (in-
ternal medicine) , James D. Hardy of Jackson (gen-
eral and thoracic surgery), William J. Carr, Jr.,
of Gulfport (pediatrics), J. Leighton Pettis of
Tupelo (ophthalmology), and Tom H. Mitchell of
Vicksburg (general practice). The committee
elected Dr. Covington chairman, and he serves
as the association’s representative on the com-
mission’s Advisory Council.

Organization of the Board. One new Trustee,
Dr. James T. Thompson of Moss Point, District 9,
was welcomed to the Board during 1969-70,
bringing to a total six new Trustees named to
the Board since 1967. Dr. Thompson succeeded
Dr. C. D. Taylor, Jr., of Pass Christian who re-
tired after 13 years service, the last of which he
served as chairman.

Officers of the Board during 1969-70 are Drs.
Mai S. Riddell, Jr., of Winona, chairman; J. T.
Davis of Corinth, vice chairman; and William O.
Barnett of Jackson, secretary.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

In its annual report to the House of Delegates,
the Board of Trustees has furnished information
* on matters relating to routine management of the
association’s affairs and matters referred to it by
the House of Delegates at the 1969 Annual Ses-
sion. A reading of the report demonstrates the
massive tasks which were carried out by the
Board of Trustees. We approve the report and ex-
press our appreciation to the Board and general
officers for their continued exercise of leadership.

The report of the reference committee was
adopted.

SUPPLEMENTAL REPORT “A” OF
THE BOARD OF TRUSTEES

Scheduling of Annual Sessions. The Constitu-
tion of the association provides for the annual
session, and under the By-Laws, it must be con-
ducted prior to the annual convention of AMA.
Section 2, Article V, of the Constitution states
that “the time and place for holding the annual
session shall be fixed by the House of Delegates,
but in emergencies, the Board of Trustees shall
have the power to fix or change either the time
or the place or both. . . .”

Since 1966, three major policy changes on
scheduling the annual session have been made

by the House of Delegates. Until 1966, the an-
nual session was scheduled on a year-to-year
basis, and by custom and tradition, it was ro-
tated between Jackson and Biloxi. Actually, these
have long been the only two cities in the state
with adequate facilities. Because of scheduling
difficulties on the year-to-year basis, the House
approved a four-year advance schedule, and the
association contracted on an alternating basis for
Jackson and Biloxi 1967-1970.

Site of Annual Session. As convention facilities
in Jackson became less satisfactory and as the an-
nual session grew in size and scope, it was noted
that attendance on the Coast was increasing. At
the same time. Coast hotel facilities were im-
proving as major hotels in Jackson were closed.

At the 99th Annual Session in 1967, the
House agreed that the 1968 meeting would be
conducted at Jackson to fulfill then-existing con-
tracts but that annual session thereafter would be
conducted on the Gulf Coast “until such time as
more adequate and suitable convention facilities
are made available at Jackson.” There is no im-
mediate prospect of improvement at Jackson, be-
cause the 300-room supermotel now under con-
struction is incapable of accommodating the meet-
ing.

Resolution No. 9. By tradition, the annual ses-
sion has been convened during the second full
week in May, thereby conflicting with Mother’s
Day and with municipal elections during years
held. Resolution No. 9 resolves “that the Board
of Trustees is empowered to alter the date of
the annual session so as to avoid these conflicts
and to make such changes as are necessary and
possible in contracts with the headquarters hotel
to accomplish this purpose.”

In implementing the resolution, the Board was
unable to alter the 1970 contract because of exist-
ing commitments by the hotel. We have, how-
ever, been able to make necessary changes for
1971 through 1973:

Annual Session

Dates

102nd

103rd

104th

105th

May 11-14, 1970
May 3- 6, 1971
May 8-11, 1972
Apr. 30-May 3, 1973

To maintain our four-year advance schedule,
the Board of Trustees recommends that the 106th
Annual Session be conducted May 6-9, 1974, at
Biloxi.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

In response to Resolution No. 9 adopted at the

AUGUST 1970

439

HOUSE OF DELEGATES / Continued

1969 Annual Session, the Board of Trustees have
authorized renegotiation of our contracts with the
Buena Vista for the 103rd, 104th, and 105th An-
nual Sessions in 1971, 1972, and 1973, respec-
tively, so as to avoid conflict with Mother’s Day
and with municipal elections.

The Board also proposes that the dates of the
106th Annual Session be fixed for May 6-9,
1974, and asks for authority to conclude the nec-
essary contracts.

We approve the rescheduling of the Annual
Sessions in response to Resolution No. 9 and the
proposed meeting dates for 1974.

The report of the reference committee was
adopted.

SUPPLEMENTAL REPORT “B” OF
THE BOARD OF TRUSTEES

Himler Report. In November 1965, the AM A
House of Delegates authorized and approved a
planning and development project through the
Board of Trustees who appointed an ad hoc
committee for this purpose. The committee re-
ported that AMA planning:

— Could be made more effective.

— That it should not be separated from man-
agement.

— That its process should be tailored to fit
AMA’s unique situation.

— Should be a commitment of leadership.

— Efforts should be to enlighten problems for
solution.

Recognition should be given to the fact that
the AMA structure presents severe limitations.

A Committee on Planning and Development
was appointed in 1968, chaired by Dr. George
Himler of New York. The report, a lengthy
document, was presented to the House of Dele-
gates at Denver in 1969, and a minority report
from Dr. John H. Budd of Ohio, a member of
the committee, accompanied the majority report.

The Himler Report is a searching and thought-
ful examination of medical care in the United
States, its manner of delivery, financing, gov-
ernmental influence, medical facilities, man-
power problems, allied professions, and the phy-
sician himself. It further touches on medical or-
ganization, health care consumers, and a host of
related areas.

The report contains 18 groups of recommenda-
tions totaling 57 in number. The minority report
contains 19 recommendations, each a modifica-
tion or refutation of a corresponding recommen-
dation in the majority report. As such, the mi-

nority report cannot stand alone as a substitute
for the majority report.

As should be expected of any major study of
this scope, challenge, depth, and candor dealing
with critical and painfully difficult problems, the
Himler Report has evoked controversy. As often
as not, opposition has been based on single state-
ments or groups of statements judged alone. Some
appear to object to the entire document as to con-
tent, but many of the recommendations flow
from existing AMA policy.

No attempt was made by the AMA House of
Delegates to act with finality on the report at
Denver, and indeed, they could not. The House
voted to name a committee to receive the re-
port, to study its content, and to refer it to the
governing bodies of constituent state medical as-
sociations.

In the latter connection, the AMA House stat-
ed that it can better act on the recommendations
“with the benefit of individual resolutions to be
submitted by the component and constituent state
associations or societies.” Your Board of Trustees
has reviewed the Himler Report and the minor-
ity report together with an analysis by our AMA
Delegates, Drs. Nelson and Hicks. They request
instructions on the wishes of the association, rec-
ognizing the magnitude of their tasks at the Chi-
cago annual convention of AMA in June.

The Board of Trustees recognizes the impor-
tance of this report and the difficulties implicit in
dealing with its recommendations. The Board
voted unanimously to transmit the report to our
House of Delegates and to publish it to the mem-
bership prior to our 102nd Annual Session, to-
gether with the minority report. The full text is
appended to this supplemental report, and the
Board hopes sincerely that every member of the
association will study it carefully and make his
wishes known.

President Royals has agreed to write every
member of the association and to invite attention
to this transmittal, asking for informed opinion
and debate.

The Board of Trustees encourages compo-
nent medical societies to generate resolutions and
policy positions on the majority and minority re-
ports herewith transmitted. We ask that indi-
vidual members of the association appear at the
reference committee hearing on this report and
discuss their views. We ask these things toward
the end of enabling our AMA Delegates to rep-
resent faithfully, accurately, and forcefully the
thinking of the association on this vital matter.

In making this transmittal, the Board also re-
cords the fact that it has conducted careful and
extensive deliberations over the majority and mi-

440

JOURNAL MSMA

nority reports. Many points made have been con-
curred in, and many have not. Our present ob-
jective is to seek the widest possible participa-
tion in our decisions by the membership in an ef-
fective effort to advance the best thinking of our
association as a contribution to the delivery of
medical service in the United States.

REPORT OF THE AMA COMMITTEE
ON PLANNING AND DEVELOPMENT

The Report of the AMA Committee on Plan-
ning and Development (Himler Report) and the
minority report (Budd Report) were published in
full text both in Volume XI, Number 4, Journal
of the Mississippi State Medical Associa-
tion, April 1970, and in the Handbook of the
House of Delegates, pages 18-55.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

The committee agrees that the Himler Report
cannot be approved or rejected in its entirety.
The committee notes that many parts of the re-
port involve established policies of the AMA, and
we recommend approval of these parts. Many
other parts involve study and gathering of infor-
mation, and we recommend approval of these
parts. The time available does not permit consid-
eration and recommendation relating to each of
its separate parts.

Your reference committee recommends that a
separate study committee be appointed to study
the report in detail and to disseminate information
to the members of the Association through meet-
ings of the component societies and the various
hospital staffs. This committee would, in effect, be
a task force with the responsibility of providing
as much knowledge of the report as possible to
each member of the association in order that de-
cisions of the association may be truly representa-
tive of the consensus of the entire membership.

Your Reference Committee associates itself in
the recommendations of our President and Board
of Trustees in requesting every member of the
association to study this report carefully and in-
form himself of its contents because of the po-
tential impact it could exert on the practice of
medicine and the delivery of health care in the
United States.

Your Reference Committee further recom-
mends that the task force report to the House of
Delegates at the 103rd Annual Session in 1971
with the object of arriving at a final policy dispo-
sition on the Himler Report.

The report of the reference committee was
adopted.

SUPPLEMENTAL REPORT “C” OF
THE BOARD OF TRUSTEES

Authorization of Building Project. The propos-
al for a needed addition to the Central Office
Headquarters building, as developed and recom-
mended by the Board of Trustees, was approved
by the House of Delegates in 1967 and reaffirmed
in 1968. Final planning and development of the
project, including financing arrangements, also
approved by the House of Delegates, were com-
pleted in late 1968 and early 1969, and the
Board invited bids on April 17, 1969. This was
reported to the House of Delegates at the 101st
Annual Session and was approved.

The architect for the project is William R. Bob
Henry, A. I. A., of Jackson. The Board of Trustees
named the Executive Committee as the Building
Committee to supervise and oversee all details in
construction and finance.

Under authorities granted by the Board, the
president signed the construction contracts and
usual agreements.

Award of Contract. The Executive Committee
received sealed bids on May 20, 1969, and the
award was made to the lowest and best bidder,
the Priester Construction Co. of Jackson. The ar-
chitect’s estimate was within 1 per cent of the
successful bid. Basic bids ranged from a high of
$114,900 to the successful bid of $100,700. Con-
tingent amounts totaled less than $5,000, also as
estimated accurately by the architect. Ground was
broken in early June, and the project was com-
pleted in February 1970.

Construction and Reporting. The addition is
framed with structural steel with reenforced con-
crete substructure and flooring. The exterior ma-
sonry matches the original building, and the qual-
ity of the addition equals or exceeds that which
was constructed in 1955-56.

The Building Committee monitored the project
closely and reported to the Board of Trustees at
each meeting during the course of construction.
Monthly reports were made to the membership
through illustrated news articles in the Journal.
The original building was repainted, and carpets
which were 14 years old were replaced.

Financing. As previously approved by the
House of Delegates, the addition was financed
with a bank loan below the prime interest rate
and certain conservations made for the addition.
The entire project, to include construction, pro-
fessional services, site improvement with a vastly
expanded parking area, equipping and decorating
totaled $129,523.95 of which $89,000 was fi-
nanced with the bank loan and $40,523.95 from

(Turn to page 458)

AUGUST 1970

441

Hi

The President Speaking

‘Our Medical Democracy’

PAUL B. BRUMBY, M.D.
Lexington, Mississippi

To attend a convention of the American Medical Association
is the treat of a professional lifetime, and to be present as a state
association officer, able to observe at close range the decision-
making process in the House of Delegates confirms the fact that
medical organization is democratic and fair.

At Chicago in June, I was impressed that an overriding desire
to do what was best for the health and welfare of the nation was
implicit in all the varied and spirited debate before the reference
committees. It was also clearly apparent that the survival of the
private physician in this environment was a matter of equal con-
cern.

Many problems were resolved at the annual convention, but
many were sent back to the Board of Trustees and the various
councils for further definitive study and work. A program for na-
tional professional liability coverage has been developed, and it
may prove to be of great value in the future.

National health insurance under many differing schemes was
thoroughly discussed and while our own Medicredit approach was
looked on with favor, other approaches had much political back-
ing. The most innovative approach to health care was a forma-
tion of closed panel corporations consisting of medical society-
sponsored foundation corporations at the state level with lesser
corporations consisting of any or all members of the local society.
These groups would furnish complete medical care on a con-
tractual basis. The actual mechanism of care and payment for
services would be a problem of local component organizations. ;
This approach is being used on the Monterey peninsula and ful-
fills the closed panel concept favored by HEW. There was a
definite feeling that present Medicaid and Medicare programs
would be consolidated into one grand centralized program.

A more standard method of reporting infant and maternal
deaths was demanded, both on a national and an international
scale. Our present method of comparing American apples with
foreign oranges is giving our detractors that famous cry that we
are the 15th among nations in infant mortality.

The final decision about abortion was the masterpiece of the
meeting. Certainly we can all go along with the decision that
abortion is a medical decision and procedure and should be per-
formed only in an accredited hospital in conformance with the
standards of good medical practice after consultation with two
other physicians chosen for their medical competence. No doctor
would perform an abortion if it violates his own moral principles.

The worry about the Himler report was abated. This report
was broken down into approximately 20 individual issues and
sent to the various reference committees which were concerned
with its context. From these committees, it was sent back to the
Board of Trustees for further consideration. Not once was that
phrase with which we are so familiar — “Without regard to race,
creed, or ethnic origin” — appended to any resolution adopted.
Democracy in American medicine does work. ***

442

JOURNAL MSM A

r

' JOURNAL OF THE

MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 8
AUGUST 1970

Decision on Abortion:
The Next 90 Days

I

rHE eye of the abortion storm may have
massed, but the backside of this medical, social,
md moral hurricane is whipping up a furor which
s not likely to subside quietly. Take note of the
ast-breaking succession of events in the past 60
lays:

— The AMA House of Delegates turned
:humbs down on a proposed physician-patient-
3nly abortion decision policy, adopting instead a
vatered-down position which can be called only
a little more liberal than the 1967 action.

— The 6,000-member National Federation of
Catholic Doctors Guilds, bitterly opposed to the
noderated AMA stand, threatened mass resigna-
tion from organized medicine.

— New York’s “on demand” abortion law with
no residence requirement became effective, and
Empire State hospitals were swamped with pa-
tient-applicants.

— Blue Cross ruled that every member plan
must provide abortion coverage to national ac-
:ount subscribers — single women included — not
just as a possible optional benefit but as a hard
:ondition of the local plan’s keeping its name,
symbol, and membership in the Blue Cross As-
sociation.

— Every state medical association meeting in
annual session during the two months period lib-
eralized its views on abortion to some extent
with Oregon and South Carolina joining the “on
demand” side of the explosive issue.

Top all this off with the frosting on the cake
when the United States Supreme Court rules on
the constitutionality of state abortion statutes this
fall. It now appears that the euphemism of the
century is the view that 1970 is a year of tran-
sition on professional and public attitudes on
abortion.

II

At the Chicago annual convention, the issue of
abortion was hardly a sleeper, but the delegates
came to debate with four pounds of Himler Re-
port and to get themselves picketed by the hippies
and yippies. Instead, an acrimonious debate ma-
terialized when a proposal hit the floor to leave
decisions on abortion strictly between the patient
and her physician. From the first, it was apparent
that the delegates were determined to stop short
of putting American medicine in the “on demand”
column.

The compromise action simply permits the pro-
cedure for socio-economic reasons where state

AUGUST 1970

443

EDITORIALS / Continued

law sanctions it but the operation may be per-
formed only in an accredited hospital after con-
sultation with two consenting physicians. The ref-
erence committee said that this position permits
the procedure by a physician “for any reason
that he determines is in the best medical interest
of the patient.”

Spokesmen for the Catholic physicians said
that the policy made M.D.’s “paid executioners.”
The federation president. Dr. Gino Patola, re-
signed his AMA membership on the spot and
called for like action by his 6,000 colleagues. It
is estimated that as many as 35,000 AMA mem-
bers are Roman Catholic.

Some AMA leaders are disenchanted with the
decision. Dr. Wesley W. Hall of Reno, Nev.,
winner of the four-way race for president-elect,
said that he “couldn’t live with the policy” on a
permanent basis. He looks for further moderation
by the Board of Trustees and House of Delegates.

Ill

“The patients came out of the woodwork on
July 1,” winced a New York medical society ex-
ecutive, commenting on the state’s new law which
has no residence requirement. Within 48 hours,
many hospitals had waiting lists numbering in the
hundreds, and some administrators were frankly
concerned about overutilization of inpatient fa-
cilities to the detriment of usual care delivery.

But two safety valves on the law may prevent
a runaway situation in New York: Guidelines is-
sued by public health authorities are introducing
aspects of restraint, and the procedure may be
performed on an outpatient basis when certain
strict medical minimum conditions are met.

The Medical Society of the State of New York
has issued guides to its 27,000 members, and these
parallel closely those of the public health de-
partment. But the state medical society guides as-
sume critical importance in that they may be-
come the practice standard for judging malprac-
tice cases. The state statute permits abortion up
to the 24th week of gestation, but both the state
society and public health department advise the
procedure by or before the 12th week. Some hos-
pitals, also empowered to adopted guides with
medical staff approval, are limiting abortion to
the 12th week.

Initially, outpatient abortions could be per-
formed in a clinic “near a hospital” with addi-
tional requirements of a standby anesthesiologist
and blood bank facilities. The Department of

Health has receded from this strict posture
permit the Planned Parenthood clinics to offer tl
procedure when qualified physicians are in a
tendance.

The operation may be offered to any worm
17 years of age or older, married or single, wii
or without parental consent, and in selected case
to younger patients. Most hospitals are limitir
admissions to bona fide residents of the stat
and many are taking only residents of the city (
county in which the institution is located. Ne
York Blue Cross had provided prepayment ben<
fits for the service.

Charges for the procedure vary widely. TI
Associated Press reported hospital charges ran;
ing from $105 for one day in New York City
1 8 municipal hospitals to as much as $350. Phys
dans’ fees were reported to range from the hig
side of that for D and C to the $250 range. TI
state society’s guides hold that after 20 week
the procedure cannot be classified as an abortic
but rather as the actual birth process. The a<
companying warning to complete registratior
and charts underscore medicine’s concern f(
medicolegal sequelae.

IV

At Biloxi last May, the state medical associ:
tion’s House of Delegates approved abortion f(

444

JOURNAL MSM

tj therapeutic indications, fetal considerations, and
th when the pregnancy results from rape or incest,
af The law presently provides for termination of
pregnancy when the life of the mother is threat-
's ened or when the pregnancy results from rape.

I[l Despite the furor which the issue has raised
nationally, only a minority of states have changed
ln! abortion laws. Since 1967, a fourth of the states
k — 13 to be exact — had modified statutes. Ten

0 states have enacted amendments which coincide
e| with the Mississippi policy position. Three states,
le Alaska, Hawaii, and New York, have “on de-
mand” laws, but the extracontinental jurisdictions

hi have stern residence requirements.

Two state supreme courts have reviewed abor-
H tion statutes, California and Massachusetts (“Abor-
S1! tion and the Law: Anachronisms Racing Science,”
£ J.M.S.M.A. XI: 335 (June) 1970). The Cali-
“l fornia tribunal swept aside its ancient law, but the
s staid New England court upheld the prohibitive
}| statute. A federal district court ruled the Dis-
c trict of Columbia law unconstitutional in U. S. v.

1

n Vuitch, and the United States Supreme Court has
°f accepted the appeal. This is the pivotal and prob-
ably decisive case in which a ruling is expected
this fall.

The indicators seem to show high pressure
from society for a modification of outdated abor-
tion laws. The AMA action cannot be con-
strued literally as opposed to the popular trend,
because half of the delegates are from states
where neither policy nor law has been changed.
If anything, the AMA moved cautiously with a
wait-and-see attitude. The rancor of the debate
really represented another aspect of the contro-
versy, not necessarily the central medical issue.

The Mississippi State Medical Association is
preparing to go to the 197 1 Regular Session of the
Legislature and seek amendments to the abortion
law in accordance with the action of the House
of Delegates. These will include therapeutic abor-
tion where the health of the mother is threat-
ened, where there is a probability that the infant
would be born deformed, or when the pregnancy
results from incest. The provision now in the law
t permitting the procedure when pregnancy results
from rape should be clarified to include forcible
and statutory rape.

Key developments to watch, in the meanwhile,
are the stability of the AMA policy, the New
York experience, further direction of the Blue
plans and the health insurance industry, and the
U. S. Supreme Court where just five men can
make the entire issue rhetorical in the next 90
days. — R.B.K.

Is the Muse
Usually Boozed?

This observation may cost the Journal some
good papers, since it attaches an unpleasant stig-
ma to the craft of writing. Dr. Donald W. Good-
win of St. Louis, professor of psychiatry at Wash-
ington University School of Medicine, believes
that writers, as a group, have a tendency to be
alcoholics.

“Whether as Hemingway said, most good
writers are alcoholics is uncertain, but apparent-
ly a large number are,” he says.

“Of the seven Americans who were awarded
the Nobel prize for literature, four, according to
their biographers, were alcoholics, and the fifth
drank heavily.”

Dr. Goodwin reports that of the well-known
American writers of the past century “quite pos-
sibly one-third to one-half could be considered al-
coholic.” He lists five principal reasons for his
premise:

— Writing is a form of exhibitionism, and al-
cohol lowers inhibitions and can bring out ex-
hibitionism.

— Writing requires an interest in people, and
alcohol increases sociability and makes people in-
teresting.

— Writing requires self-confidence, and alco-
hol bolsters it.

— Writing is lonely work, and alcohol as-
suages loneliness.

— Writing requires intense concentration, and
alcohol relaxes.

Dr. Goodwin goes on to contend that careful
writing consists of an endless chain of small de-
cisions, choosing the best work, excluding this,
including that, and the good writer, while work-
ing, is an obsessional. He argues that restricting
obsessions to the 8-to-5 workday is difficult, as
the wheels of the mind keep turning. He reports
that writers are notorious sufferers of insomnia, so
they turn to the cup that cheers for emancipation
from the tyranny of mind and memory.

In defense of the origin of the printed word,
let it be noted that virtually every art form ful-
fills Dr. Goodwin’s criteria for the writer boozing
it up. So do many forms of work in this world of
technology. Let us take whatever comfort there
may be in the view of medicine that alcoholism
is a disease, albeit within the realm of possibility
that honest, hard work could exacerbate it.

Please have no fears in submitting manuscripts
to the Journal: The Editors have yet to give
one the sniff test. — R.B.K.

AUGUST 1970

445

EDITORIALS / Continued

The Durability of the
Hill-Burton Act

President Nixon suffered his first drubbing on a
veto after a year and a half in office when the
Congress overrode his disapproval of the 1970
amendments to the Hill-Burton Act. A strange
alliance of Southern conservatives joined forces
with Northern liberals to carry the day against
the President.

The $1.26 billion program carried certain
strings which the White House couldn’t swallow.
It continues the formula of grants for hospital
construction first begun in 1948 as well as $1.5
billion in federal loan guarantees with the gov-
ernment obligated to pay up to 3 per cent of in-
terest charged.

The President had asked Congress to dis-
continue the grants and to substitute instead a sys-
tem of loans for hospital construction and mod-
ernization. The Senate ignored the plea, passing
a generous measure which was trimmed in con-
ference with the House of Representatives. More-
over, the provisions require the administration
to spend the entire appropriation within the fiscal
year.

The latter provision added insult to injury in
incurring the Presidential wrath. The White House
said that a program is pointless if the executive
department has no discretion to exercise over it.
Capitol Hill observers say that the spend-all
clause was put into the bill after the administra-
tion dragged its feet on spending other health
appropriations.

Southerners voted to override the President,
because the 1970 amendments provide extra help
for low-income states. The Northerners want fed-
eral money under whatever condition it is avail-
able. The combination was unbeatable for the
party stalwarts who lost badly in their effort to
sustain the veto.

A veto and subsequent override on an ap-
propriations measure involving only slightly more
than one-half of 1 per cent of the budget is nor-
mally not big news. But a clear pattern emerges
in the attitude of the states toward preserving an
institution which has been accepted with near-
universal acclaim, the Hill-Burton formula for
hospital construction financing. It will probably
remain on the health care scene for decades to
come. — R.B.K.

Muscle Busters Are
Not Dum-dums!

Physical fitness has been receiving the empha-
sis long its due with just about everybody getting
into the act. We have the President’s Council on
Physical Fitness which has been able to attract
such stellar personalities as Stan Musial as chair-
man. But the skilled individuals who devote their
careers to physical fitness, those with degrees in
physical education, are generally regarded as oc-
cupying a low rung on the academic ladder.

Theodore W. Landphair, writing in The Na-
tional Observer , notes that “in most places, physi-
cal education ranks with typing and remedial
English in esteem and professorial pecking or-
der.” He says that when a football player is in-
troduced as an engineering major, the reaction is
that “he’s bright for an athlete,” but when the
same player is identified as a PE major, he’s
just another dum-dum.

Landphair writes that at State University Col-
lege at Brockport, N. Y., there is a new look for
physical education. The department threatens the
philosophers and scientific eggheads as it seeks a
new image for the physical education major and
professor.

Brockport will henceforth refer to its PE de-
partment as that of “sport science,” relating more
to cultural phenomenon than to sweaty athletes

“/ have good news for yon — but first, would you
mind drinking this?”

446

JOURNAL MSM A

straining against the weights. In fact, the school’s
new working definition of sport is “the act of
vying physio-cognitive behavior against an ob-
stacle in a competitively structured, institution-
alized situation.-'

Brockport officials say that the new look for
physical education is long overdue, because the
nation, during the autumn months, bets $135 mil-
lion a week on football, and respected newspapers
devote five or six pages daily to sports.

Whatever the case at Brockport, we use the
amusing story to underscore the merit in physical
fitness and to record esteem for those who teach
and coach. Called by any name, the work of
building sound bodies is a worthy and meritori-
ous calling. — R.B.K.

The Bittersweet
Issue of Cyclamates

The Food and Drug Administration’s decision
on cyclamates is getting another roasting from
Congress, this time for permitting further use of
the substances in dietary foods. Rep. L. H. Foun-
tain (D., N. C.), chairman of the House Gov-
ernment Operations Subcommittee, has blasted
HEW Secretary Elliott Richardson’s department
for inconsistency and possible illegal action.

Rep. Fountain charges that cyclamates, ordered
off the mass market because evidence showed
they produced bladder cancer in laboratory ani-
mals, are now being treated as a drug by FDA in
issuing permission to use them in dietary foods.
Yet, Fountain said, there has been no testing and
investigation required for a new drug.

He said that the food sales would be uncon-
trolled and could result in widespread use of a
dangerous substance. His argument centers around
the order issued by former HEW Secretary Rob-
ert Finch under the Delany Amendment which
prohibits any supplement which can be shown to
produce cancer in animals or man.

The ruckus is only the tip of the iceberg, be-
cause cyclamate makers, hard hit by the order,
are working quietly behind the legislative scenes
on government subsidies to recoup part of the
losses when the $100 million industry was vir-
tually wiped out. Many feel that the dietary food
provision is part of the ploy.

The entire matter has been clouded by sur-
prise moves, sudden bureau decisions, and un-
expected reactions from Congress and executive
departments. In the meanwhile, an estimated 3
million patients need foods with non-nutritive

sweeteners as essential adjuncts to preventive ther-
apy. Let’s have a quick end to the politicians’
handling of this matter and get it into the hands
of the scientists. — R.B.K.

CIRCUIT COURSES

University of Mississippi Medical Center Circuit
Courses will resume in the fall for the 13th con-
secutive year. Supported by a grant from E. R.
Squibb and Sons, the postgraduate hometown
refresher series is presented by the University of
Mississippi School of Medicine, the Mississippi
Academy of General Practice and the Mississippi
State Medical Association. Circuit Courses on the
1970-71 roster will return to last season’s eight
host cities.

FUTURE CALENDAR
November 4, 1970

Pulmonary Seminar (Tentative Date)
December 1 1 , 1970

Gynecologic and Obstetrical Infec-
tions Seminar

Dr. Lampton Named
RMP Director

Dr. T. D. Lampton has been named director
of the Mississippi Regional Medical Program head-
quartered at the University of Mississippi Medi-
al Center in Jackson.

Former assistant MRMP coordinator, Dr.
Lampton is a graduate of Millsaps College and
the University of Mississippi School of Medicine,
where he is a medicine assistant professor. He
took his internship at the University of Texas
Branch Hospital in Galveston and his internal
medicine residency at the University of Missis-
sippi Medical Center.

In 1968, Dr. Lampton joined the Medical Cen-
ter staff as an instructor in medicine and MRMP
categorical coordinator for stroke and heart dis-
ease. As director, he assumes a newly-created
post, with Dr. Guy D. Campbell serving as Mis-
sissippi Regional Medical Program coordinator.

AUGUST 1970

447

ORGANIZATION / Continued

Lewis, Fredric Austin, Jackson. Bom Fayette-
ville, Ark., November 30, 1939; M.D. Tulane
University School of Medicine, New Orleans, La.,
1965; interned Charlotte Memorial Hospital,
Charlotte, N. C., one year; pathology residency,
same, five months; radiology residency, same,
Jan. 1967-Oct. 1969; elected May 5, 1970, by
Central Medical Society.

Dean, Sara Ruth, Canton. M.D., University of
Virginia School of Medicine, 1922; interned Uni-
versity of Virginia Hospital, one year; residency,
New England Hospital for Women and Children,
Boston, Mass., 1923-1924; residency. Children’s
Hospital, Denver, Colo., 1926-1928; died Feb. 24,
1970, age 71.

John K. Abide of Cleveland announces the mov-
ing of his offices to 801 First Street. Dr. Abide
was formerly located on Commerce Street.

James W. Allison has associated with the Vicks-
burg Clinic in the department of general practice.

A. V. Beacham of Magnolia has been appointed
by Gov. John Bell Williams to serve on the Mis-
sissippi Commission of Hospital Care. Dr. Beach-
am is a former director of the Alcoholic Beverage
Control division.

Hugh L. Boyd announces the opening of his
office for general practice at 1200 Washington
Avenue, Ocean Springs.

Louis Jennings Owens has associated with his
father-in-law, Charles E. Catchings of Wood-
ville, in the practice of medicine at the Catchings
Clinic.

Douglas L. Conner of Starkville is a member
of the newly-formed committee of Mississippi
business and professional leaders, whose purpose
is to assist the state in moving peacefully into
further school desegregation.

Marion E. Cockrell, Jr., of Laurel has quali-
fied as a diplomat of the American Board of Ob-
stetrics and Gynecology and is now a fellow of
the American College of Obstetrics and Gynecol-
ogy.

Harris Vann Craig of Natchez was speaker at a
special Mississippi Heart Association-sponsored
meeting for physicians from Natchez and adjoin-
ing areas. His topic was techniques of cardio-
pulmonary resuscitation.

William N. Crowson of Clarksdale has ac-
cepted the post of assistant chief of surgery at the
Veterans’ Administration Hospital in Memphis,
effective Aug. 1 . Dr. Crowson will also become
assistant professor of surgery at the University of
Tennessee School of Medicine in Memphis.

Robert Donald of Pascagoula is that city’s Jaycee
of the Year. Dr. Donald was recognized at the
special awards banquet for founding the Jaycee
International Medical Supplies Project.

Leonard W. Fabian of Jackson and UMC was
visiting professor at Montefiore Hospital in New
York City recently.

Elmo P. Gabbert, formerly of Fayette, an-
nounces his association with J. W. Hollings-
worth of Meadville for the general practice of
medicine.

Ephraim S. Garrett, Jr., of Biloxi has received
a “second diploma” in honor of the 50th anni-
versary of his graduation from Tulane Univer-
sity. Dr. Garrett attended the University’s 1970
graduation when diplomas were presented to the
1920 graduates.

Armin F. Haerer of Jackson and UMC partic-
ipated in a workshop sponsored by NIH on
anticonvulsant levels. The conference was held
in Warrington, Va.

Jim G. Hendrick of Jackson has been appointed
a member of the Committee on Public Informa-
tion of the American Academy of Pediatrics. The
seven-member committee was named by the AAP
Executive Board as a permanent arm of the
Academy.

George Henneberger announces the opening of
his office for the practice of obstetrics and gyne-
cology at the Women’s Clinic at 1618 Ingalls
Avenue in Pascagoula.

448

JOURNAL MSM A

Leroy Howell of Starkville has been notified of
his passing the examination and other qualifica-
tions to become a diplomate of the American
Board of Family Practice.

Ben B. Johnson of Jackson and UMC partici-
pated in the Mississippi Kidney Foundation
program for the joint meeting of the Clarksdale
Lions, Rotary. Exchange, and Civitan Clubs.

Andy E. Kirk of Starkville announces the re-
location of his office at 209 South Lafayette.

Herbert G. Langford of Jackson and UMC met
with the American Heart Association risk factor
screening committee in Minneapolis recently.

Harold G. Magee of Yazoo City was presented
a Mississippi Jaycee Governor award by the Ya-
zoo County Jaycees at their installation banquet.
The award is a recognition of outstanding con-
tributions to and achievement in the Jaycee or-
ganization.

John A. Murfee, Jr., announces the opening
of his office for diseases of the ear, nose and
throat and plastic surgery of the head and neck
at Medical Arts Building, 221 Seventh Street
North, Columbus.

Shanti Pandey has opened offices for the prac-
tice of general medicine and specializing in ob-
stetrics and gynecology at the corner of Harrison
and Magnolia Streets in Fayette. He is associated
with Enrique Flechas.

Ben B. Rader, Jr. has associated with William
E. Lotterhos, Hardy Woodbridge, and Ben-
jamin F. Banahan, Jr. in the practice of family
medicine at the Family Medical Center, 4660 Mc-
Willie Drive, in Jackson.

E. P. Robbins of Brookhaven announces the re-
moval of his office from the Medical Building, 222
South Church Street, to 136 East Chippewa Street.

Virginia Tolbert of Ruleville gained a seat on
the Ruleville Board of Aldermen in a runaway
victory over three other contenders recently in a
special municipal election.

James C. Totten, Jr. of Pascagoula presented a
program on air and water pollution in Jackson
County to his medical society at its quarterly
meeting. The Singing River Medical Society has
now undertaken a study of pollution within Jack-
son County.

James C. Waites of Laurel has been elected to
the board of directors of Laurel Federal Savings
and Loan Association.

Noel C. Womack, Jr., of Jackson has been ap-
pointed chairman of the Task Force Committee
on Health by William E. Lotterhos of Jackson,
chairman of the Governor’s Committee on Chil-
dren and Youth.

MSU Announces
Seminar in Hypnosis

A new graduate course. Seminar in Hypnosis,
has been introduced at Mississippi State Univer-
sity. The three semester hour course will be
taught by Department of Educational Psychol-
ogy associate professor. Dr. J. M. Woolington.

The course is designed to acquaint the student
with the theoretical and applied aspects of hyp-
nosis, stressing appropriate experimental and clin-
ical techniques. Lectures will cover the major di-
visions: introduction to hypnosis, history, theo-
ries, suggestibility, phenomena, stages (depths)
of hypnosis, psychodynamics of hypnotic induc-
tion, techniques and applications.

Registration will be open only to ( 1 ) advanced
graduate students majoring in psychology or edu-
cational psychology, (2) students who are enrolled
in medical or dental school, and (3) physicians,
dentists, and psychologists who are currently em-
ployed but wish to increase their knowledge and
proficiency in this area. Medical interns and resi-
dents are also eligible.

Seminars will be offered periodically accord-
ing to demand. Initially, the course will be
taught on campus one night per week, two and
one-half hours per night, for fifteen weeks. The
Division of General Extension is making future
arrangements for offering the course anywhere
in the state where need arises.

A minimum of between five and ten persons
will be needed to materialize a class in a par-
ticular area. Estimated cost is about $200.00 per
person. Depending on the needs of the local in-
dividuals involved, the class could be conduct-
ed one or more nights weekly or on weekends to
get in a total of 3 7 Vi hours of instruction.

Dr. Woolington has had 15 years of experi-
ence in this field and is qualified as an “expert
witness” to give testimony in court in the field of
hypnosis. He is a licensed psychologist and holds
membership in the Mississippi, Southeastern and
American Psychological Associations, American
Orthopsychiatric Association, American Society of
Clinical Hypnosis, and Society for Clinical and
Experimental Hypnosis. He is a Diplomate in Ex-
perimental Hypnosis (American Board of Exam-
iners in Psychological Hypnosis).

AUGUST 1970

449

ORGANIZATION / Continued

UMC Ups
Faculty to 182

The University of Mississippi Medical Center
has added 23 faculty members since January,
1970, upping the total of full-time medical and
nursing faculty to 182.

Two new professors have joined the School of
Medicine, Dr. James R. Dawson, Jr., pathology,
and Dr. Joe Robert Norman, medicine.

Dr. Norman, who is Christmas Seal professor of
pulmonary diseases and associate professor of
physiology and biophysics, holds a B.S. degree
from Howard College and an M.D. degree from
the Medical College of Alabama. He did both his
internship and residency at the Medical College of
Alabama, where he was appointed instructor in
medicine, advancing to associate professor.

Prior to his Mississippi appointment, Dr. Daw-
son had been chairman of the pathology depart-
ment at the University of Minnesota School of
Medicine since 1949. He earned B.A. and M.D.
degrees from Vanderbilt University, where he also
took his internship and residency. He is a former
faculty member of Cornell University and Van-
derbilt University Schools of Medicine.

School of Medicine additions at the assistant
professor level include Dr. Ernst Schmidt, phar-
macology; Dr. Jesse G. Mullen, anesthesiology;
Dr. Thomas Sajwaj, psychiatry; Dr. Joseph Lin-
coln Arceneaux, microbiology; Dr. James M.
Goodman, surgery (surgical illustrations) and de-
partment art director; Dr. H. Davis Dear, med-
icine, and Dr. Harris J. Granger, physiology and
biophysics.

Instructor appointments in the medical school
are Dr. Harvey N. Chapin, psychiatry; Dr. Rob-
ert J. Hamernik, anesthesiology; Malcolm Donald
May, medicine (inhalation therapy); Ojus Mal-
phurs, Jr., surgery (otolaryngology); Dr. Ronald
Gordon Benson, obstetrics and gynecology; Dr.
Ancel C. Tipton, Jr., medicine (neurology); Hays
Williams, anatomy, and Dr. Lynda Lee, pre-
ventive medicine (medical genetics) and pediat-
rics. Miss Mary Joan Rouke is a new associate
in obstetrics and gynecology in connection with
the nurse midwifery program.

New School of Nursing faculty are associate
professor Mrs. Themetris Emma J. Highsmith, as-
sistant professors Mrs. Ethel R. MacArthur and
Mrs. Helene A. Willingham and instructors Mrs.
Barbara Kay Cater and Mrs. Landa Gayle Strum.

Family Planning
Serves Four Counties

The State Board of Health’s Family Planning
Project is currently serving over 1800 patients in
Hinds, Madison, Rankin and Warren counties, ac-
cording to Dr. H. B. Cottrell, executive officer,
State Board of Health.

An average of 21 clinics are held each month,
and an average of 18 patients are seen at each
clinic, according to Dr. W. E. Riecken, Jr., di-
rector of the project.

The project staff now consists of Dr. Riecken,
a supervising nurse, three clerks and two health
aides, working at a location on Woodrow Wilson
Avenue.

This staff supplements the personnel of the
various county health departments, and medical
services also are provided by OB-GYN resi-
dents at the University of Mississippi Medical
Center.

The staff also maintains a central register of
family planning for Hinds County in cooperation
with the Community Services Association (OEO)
project in Hinds County.

A report by Dr. Riecken summarizing the ac-
tivities of the program during its first ten months
of existence (it began July 1, 1969) shows 207
clinics held and a total of 2217 visits by the
1822 patients.

The report also shows that 46 per cent of the
women using the service expressed a preference
for oral contraceptives, while 44 per cent chose
intrauterine devices. Six per cent chose creams
or foams, and three per cent chose use of a
diaphragm, while one per cent chose various
other means of contraception.

Occupational Health
Congress Slated

The 30th Annual AMA Congress on Occupa-
tional Health is set for Sept. 30-Oct. 1, 1970, in
Los Angeles.

Sponsored by the AMA Council on Occupa-
tional Health, the Congress will convene at the
Century Plaza Hotel. The Congress program is
acceptable for 12 Vi elective hours by the Ameri-
can Academy of General Practice.

The annual Physician’s Award of the Presi-
dent’s Committee on Employment of the Handi-
capped will be presented during the Congress
program at noon, Oct. 1.

There is no registration fee, and all interested
persons are invited to attend.

450

JOURNAL MSM A

Format Announced for 103rd Annual
Session; Exhibits, Essays Are Invited

The Council on Scientific Assembly has an-
nounced the schedule of section meetings for the
103rd Annual Session and invited papers and
exhibits from the membership. The 1971 con-
clave is set for Biloxi
May 3-6, 1971.

Dr. Raymond S.
Martin, Jr., of Jack-
son, chairman of the
15-member council,
said that the seven
sections of the Scien-
tific Assembly will
meet on three of the
four convention days
with Monday re-
served for the House
of Delegates and ref-
erence committees.

“By issuing this
early invitation,” Dr. Martin said, “we hope to
encourage the membership to participate actively
by presenting papers and scientific exhibits.”

The council’s announcement said that members
interested in presenting papers should send ab-
stracts to appropriate section officers at the earli-
est date. The sections will choose in-state or mem-
ber essayists by or before the end of the year,
Dr. Martin said.

Expressing satisfaction that the 1970 scientific
exhibit was the largest in annual session history,
i the council acted to add to participation incen-
tives. The cash purse or honorarium for the best
scientific exhibit by a member or members of
the association will be continued. Dr. Martin said.
In addition, there will be two honorable mention
awards, and every author in the scientific ex-
hibit will be presented with a certificate of par-
ticipation.

The council will continue to separate scientific
exhibits as to those presented by association mem-
bers and out-of-state guests. Out-of-state exhibits
are not eligible for the honorarium but do com-

pete for the Scientific Achievement Award, a
bronze medallion.

The announcement said that Monday, May 3,
will be devoted to the opening meeting of the
House of Delegates at which Dr. Walter C. Borne-
meier of Chicago, president of the American
Medical Association, will speak. Reference com-
mittee meetings and hearings on resolutions and
reports are slated for the afternoon segment of
the first day.

The Scientific Assembly and all exhibits open
Tuesday morning, May 4, with the general session
on obstetrics and gynecology set for 9:00 o’clock.
Surgery meets at 2:00 o’clock in the afternoon,
and plans have been made for concomitant meet-
ing that day of the Mississippi Chapter of the
American College of Surgeons.

Three general sessions are scheduled for
Wednesday, May 5, with the morning devoted to
the general session on medicine. The afternoon
programs, moved up half an hour to 1:30, in-
clude preventive medicine and general practice.
An association-wide social occasion has been put
on the evening agenda for Wednesday, the coun-
cil said.

The closing day of the meet features simul-
taneous morning sessions of pediatrics and eye,
ear, nose, and throat with the adjourned meet-
ing of the House of Delegates and election of
1971-72 officers set for the afternoon.

Dr. Martin said that as many as 15 specialty
society and related meetings will occur during the
four-day convention. Another feature to be con-
tinued under a revised format is the medical mo-
tion picture program which will be presented daily
at the conclusion of morning general sessions.

Members interested in presenting papers be-
fore any of the seven general sessions are en-
couraged to write section officers, furnishing an
abstract of the proposed essay. 1970-71 section
officers are:

— EENT: Dr. Richard L. Blount of Jackson,

Dr. Martin

AUGUST 1970

45 1

ORGANIZATION / Continued

chairman, and Dr. James K. Williams of Pas-
cagoula, secretary.

— General Practice: Dr. James O. Stephens of
Magee, chairman, and Dr. W. Johnson Witt of
Jackson, secretary.

— Medicine: Dr. C. Ralph Daniel, Jr., chair-
man, and Dr. S. H. McDonnieal, Jr., secretary,
both of Jackson.

— Obstetrics and Gynecology: Dr. William S.
Cook of Jackson, chairman, and Dr. Warren
Plauche of Biloxi, secretary.

— Pediatrics: Dr. John D. McEachin of Meridi-
an, chairman, and Dr. John R. Jackson, Jr., of
Hattiesburg, secretary.

— Preventive Medicine: Dr. Hugh B. Cot-
trell, chairman, and Dr. Frank M. Wiygul, Jr.,
secretary, both of Jackson.

— Surgery: Dr. M. Beckett Howorth, Jr., of
Oxford, chairman, and Dr. Benton M. Hilbun of
Tupelo, secretary.

Dr. Martin said that applications for scientific
exhibit space should be addressed to him or the
council at the state association headquarters, 735
Riverside Drive, Jackson 39216. Applications
should be made in letter form, he added, and
should include the title of the exhibit, names of
authors, minimum requirements in linear feet of
wall space, and any special requirements such as
special electrical service or other needs not usual-
ly furnished by convention hotels.

The council said that plans are being made
for medical alumni occasions and include Ole
Miss, Tennessee, Tulane, and Vanderbilt. Addi-
tional innovations, designed to improve the value
and attractiveness of the annual session, will be
announced soon. Dr. Martin said,

AMA Staff
Reorganizes

The AMA Department of Postgraduate Pro-
gram has been divided into the Department of
Medical Instrumentation and the Department of
Scientific Assembly. The former will be directed
by Dr. Ralph E. DeForest, and the latter by Ralph
P. Creer.

This separation was decided upon by the AMA
Board of Trustees at its meeting in Washington,
D. C.

The Board also changed the name of the Com-
mittee on Emergency and Disaster Medical Care
to the Committee on Emergency Medical Ser-
vices. It asked the members to advance liaison

with state medical societies in order to stimulate
wider planning and implementation of emergency
and disaster care programs.

Dr. Mitchell Is
New SBH Appointee

Dr. Shelby W. Mitchell, director of the Jones
County Health Department for the past 14 years,
has been appointed director of Local Health Ser-
vices of the Mississippi State Board of Health,
effective July 1.

He succeeds Dr. Steven L. Moore, who left
the State Board of Health some six months ago
to take over the directorship of State Compre-
hensive Health Planning.

In announcing Dr. Mitchell’s appointment,
State Health Officer Hugh B. Cottrell said, “Dr.
Mitchell comes to the state health department
with a keen knowledge of the operation of public
health on a local level, and his direction and
guidance to the state’s 82 county health depart-
ments will make for an efficient overall opera-
tion.”

In 1956, Dr. Mitchell became health officer of
Jones County, and shortly thereafter Jasper and
Covington Counties united with Jones to form a
health district, which he has directed continuous-
ly-

Last December, Dr. Mitchell’s responsibilities
were greatly increased when he was named act-
ing director of 12 county health departments in
the central and southern part of the state — Lau-
derdale, Newton, Scott, Smith, Simpson, Copiah,
Lamar, Forrest, Perry, Pearl River, Hancock and
Harrison.

A native of Copiah County, Dr. Mitchell at-
tended Copiah-Lincoln Junior College and earned
the B.S. degree at Mississippi College and the
M.S. degree at the University of Mississippi.

He completed the first two years of his medical
studies at the University of Mississippi Medical
School in Oxford, where he was president of his
class, and received the M.D. degree from the
Medical College of Alabama. He holds the de-
gree of Master in Public Health from the School of
Public Health, Tulane University.

Following his internship at Lloyd Nolan Hos-
pital, Fairfield, Alabama, Dr. Mitchell returned to
Mississippi and served as staff physician at El-
lisville State School for one year before entering
public health service.

Dr. Mitchell and his wife. Dr. Maura J. Mitch-
ell, who is a practicing physician, make their home
in Ellisville, where she is associated with the El-
lisvi lie State School.

452

JOURNAL MSM A

Book Reviews

Symposium on Cancer of the Head and Neck —
Total Treatment and Reconstructive Rehabilita-
tion. By John C. Gaisford, M.D., Editor. 381
pages with 583 illustrations. St. Louis: The C. V.
Mosby Co., 1969. $31.50.

This symposium with 54 distinguished con-
tributors was presented in Pittsburgh in Dec., 1968.
The various authors present the overall manage-
ment of head and neck cancer with emphasis on
reconstructive rehabilitation by various plastic
surgical technics.

A comprehensive survey of the problem is pre-
sented under ten separate headings. The subjects
which were assigned to the individual authors are
well covered. There are a few errors which were
not corrected in proofreading. For example, on
page 17 the dosage of Keflin is presented as 10
grams every four hours, far in excess of the rec-
ommended dosage.

The symposium was sponsored by the Educa-
tional Foundation of the American Society of
Plastic and Reconstructive Surgeons, Inc. and will
be chiefly of interest to plastic surgeons. The
background material is of interest to other spe-
cialists who work in this field, as well as to gen-
eral surgeons with a special interest in head and
neck cancer surgery. Rapid changes in radiation
therapy and chemotherapy, as well as in surgery,
limit the period during which the decisions reached
will be authoritative.

The sections on the surgical management of
radioosteonecrosis of the head and neck and on
problem tumors of the head and neck are par-
ticularly interesting.

The recorded round table discussions at the end
of each of the ten sessions add to the enjoyment
of the volume.

The book is definitely of interest to anyone
seeking a broad view of head and neck cancer,
and it will be of greatest interest to the plastic
surgical resident and specialist.

W. C. Shands, M.D.

Personnel Administration and Labor Relations
in Health Care Facilities. By James O. Hepner,
Ph.D.; John M. Boyer; and Carl L. Westerhaus.
370 pages. St. Louis: The C. V. Mosby Co., 1969.
$15.00.

Probably the most compelling area in health
care management today provides the subject of
this volume. Inclusion of hospitals and similar in-
stitutions under the Fair Labor Standards Act and
other related federal statutes has occasioned a
marked increase in the “payroll increment” of
institutional costs. On a national level, personnel
cost represents approximately 70 per cent of the
total operating costs of hospitals.

Another area that has entered the management
picture with impact is that of labor relations. A
concerted effort is being mounted by organized
labor to unionize hospital and other health fa-
cility employees. Health care employees are par-
ticularly attractive to labor unions both as to
their number and the potential dues dollar.

Our current health institution managers are not
experienced in these areas simply because it has
never been a “necessary” interest as to day-to-
day operations. As a result most are finding it
necessary to become knowledgeable and proficient
in the shortest possible time in personnel man-
agement and labor relations.

The authors have produced a volume which
should be useful to any person involved with the
management of health care facilities, as well as
to those who may have a continuing interest in
the forces at work within the health care delivery
system. Dr. Hepner teaches in a graduate pro-
gram for health care administration while Messrs.
Boyer and Westerhaus are personnel managers.

The first half of the book is devoted to a gen-
eral overview of the hospital as an institution and
its behavior, organization and economics. Person-
nel management and administration are viewed
in conceptual terms. The latter chapters of the
volume are more specific in dealing with person-
nel policies and procedures, legislation, collective
bargaining, health manpower needs and train-
ing.

C. Chandler Clover. F.A.C.H.A.

AUGUST 1970

45 3

ORGANIZATION / Continued

UMC Establishes
Home Dialysis Unit

Now dialysis patients at the University Medical
Center can pack up and go home for good, taking
their artificial kidneys with them.

A recently-established home dialysis training
center enables patients to train at the Medical
Center, then transfer to their own home units, ex-
panding the UMC artificial kidney unit into a
state-wide program.

By removing restrictions caused by the limited
number of kidneys in the Jackson unit and drastic-
ally cutting the cost of dialysis, the home plan
opens up the lid on how many Mississippi lives
can be saved.

Hospital dialysis runs about $10,000 per pa-
tient annually, while a home unit takes only
around $3,000 for supplies after the initial $6,000
equipment outlay. The home training project is
funded by the Department of Vocational Rehabil-
itation, the Kidney Foundation and other donors,
including the Association of Operating Room

A late-June open house formally initiated the new
home dialysis training center at the University Med-
ical Center. The home program, established with
$30,000 in Kidney Foundation funds which were
matched four-to-one by the Department of Voca-
tional Rehabilitation' s $120,000 is aimed at teaching
dialysis patients self care. Among principals were,
from left, vocational rehabilitation state director
John Webb, home dialysis patient-trainee David
Lammons of Belzoni, assistant nursing supervisor
Mrs. Peggy Baugh and Hinds County Kidney Foun-
dation outgoing president Dr. H. C . Ricks.

Technicians and interested individuals. Additional
support from Mississippi Regional Medical Pro-
gram helps train the backup medical team.

The Kidney Foundation raised $30,000 through
private contributions, matched on a one-to-four
basis with a $120,000 grant from the Vocational
Rehabilitation Department, which also helps qual-
ified home patients in purchasing kidneys and
first-year supplies.

Set up to train a class of four patients in an
eight-week course, the home center will con-
stantly be in use. As each group “graduates,” a
new class from the principal chronic unit will be-
gin. Six “alums” are already home with their
units and another class is in session.

Other health professionals, including physi-
cians, nurses, technicians, dieticians, administra-
tors and social workers can also take advantage
of the new facilities. A Medical Center nephrolo-
gy course, offered as part of the University of
Mississippi Postgraduate Institute in the Medical
Sciences, prepares hometown physicians to work
with their patients’ units.

The artificial kidney unit at the Medical Cen-
ter, besides maintaining patients on the waiting
list for home training, will ultimately serve as a
mechanical and medical backup for home pa-
tients and continue to be an emergency unit for
acute hospital inpatients.

This decentralization of the UMC unit, which
will take dialysis-dependent patients through the
main unit back to their homes, is aimed at elim-
inating long-term hospital care. And that goal,
kidney unit officials agree, is gradually nearing
attainment.

SBH Now Finances
Immunizations

The State Board of Health picks up the tab,
starting July 1, for immunization programs
which, for the past eight years, have been largely
federally financed.

One example is the measles program.

The federal Vaccine Assistance Act of 1962,
through which federal funds bought vaccines in
huge quantities for state use, was enlarged in
1965 to include measles vaccine.

The federal program expired a year ago, and
the state now must buy most of its own vaccine.

Dr. Durward Blakey, director of the agency’s
Division of Preventable Disease Control, said that
measles vaccine was ordered for the fiscal year
starting July 1.

“There may be some counties,” he said, “where
reserve supplies have run low and where indi-

454

JOURNAL MSM A

viduals asking for a measles immunization have
had to have it postponed.

“But we now have adequate amounts to con-
tinue the maintenance program we began about a
year ago, after the blitz which effectively cut
down the measles threat.”

The “blitz” to which Dr. Blakey referred saw
the State Board of Health administer 300,000
doses of measles vaccine, starting in April of
1966, when the vaccine first became available.

“That massive effort,” said Dr. Blakey, “en-
abled us to bring measles under control enough
so that we now need smaller amounts of vac-
cine— enough for a good maintenance program.”

The maintenance program, he said, immunizes
children as they reach the age of one and in-
volves private physicians as well as the State
Board of Health. He called this “keeping up with
the birth rate.”

Some federal funds for vaccines, he said, are
still available to the State Board of Health, but
these funds are limited to immunizations for
Rubella, or German measles— a major cause of
birth defects.

Dr. Blakey noted an increase in measles in the
state, with 65 cases of measles so far this year
as compared to 24 cases for the entire previous
year.

Dr. Blakey said this is not considered a serious
increase, since “better surveillance” of measles
cases could account for some of the increase.

He said measles immunization is important,
however, and he said the supply ordered by the
State Board of Health “is sufficient to maintain a
safe level of immunization for the state.”

Hospital Association
Elects Officers

Lowery A. Woodall, executive director of For-
rest General Hospital in Hattiesburg, was elected
Mississippi Hospital Association president for
1970-71 at the 39th annual convention at Biloxi.
Outgoing MHA president is Richard H. Malone,
president of Hinds General Hospital in Jackson.

The new president-elect is James L. Townsend,
administrator of East Bolivar County Hospital in
Cleveland.

Malone was elected MHA delegate to the
American Hospital Association, and D. A. Lingle,
administrator of King's Daughters Hospital in
Greenville, was named alternate delegate.

Named to the MHA Board of Governors were
Thomas O. Logue, Jr., Southwest Mississippi Gen-

eral Hospital, McComb; D. Andrew Grimes, di-
rector of University Hospital in Jackson; and
Charles W. Shepherd, Watkins Memorial Hospital
in Quitman.

The delegates elected C. Philip Wimberly, Me-
morial Hospital, Gulfport, as Speaker of the
House of Delegates, succeeding C. Chandler
Clover, Doctors Hospital of Jackson.

Named to the board of Blue Cross were Fred
Lavender, Noxubee General Hospital, Macon, and
Lowery Woodall.

Dr. Dan Mitchell Is
Alum President-Elect

Dr. J. Daniel Mitchell of Jackson has been
named president-elect of the University of Mis-
sissippi Medical Alumni. He will take office in
June, 1971.

Long active in organized medicine. Dr. Mitchell

is a member of Cen-
tral Medical Society,
Mississippi State Med-
ical Association, and
the American Medical
Association. He has
served as chairman of
the Public Health and
Legislation Committee
for Central Medical
Society and is current-
ly MSMA Mid-State
vice president. He is
secretary-treasurer of
the Mississippi Medi-
cal Political Action

Committee.

Dr. Mitchell was assistant chief of staff at
Hinds General Hospital and became Chief of
Staff in 1969. He is a member of the Long Range
Building Committee for Hinds General.

The Jackson general practitioner is a member of
the Board of Directors for the Ole Miss General
Alumni Association and served as a member of
the Building Committee for the Medical Alumni
House on the Jackson campus of the University.
He is presently on the Steering Committee for
the operation of the Medical Alumni House and
is class representative of his medical class of
1954 for the UM Alumni Association.

He received his B.A. degree from the Uni-
versity of Mississippi and completed two years of
medical school there before earning his M.D. de-
gree from the University of Tennessee. Dr. Mitch-
ell interned at St. Joseph Hospital in Memphis.

Dr. Mitchell

AUGUST 1970

455

ORGANIZATION / Continued

Surgery on Coronary
Artery Course Set

The Adolf Gundersen Medical Foundation and
the Wisconsin Heart Association will present a
Symposium on “Surgery and the Coronary Artery
— An Evaluation’’ on Sept. 23, 1970. The course
will take place in Valhalla Hall, Wisconsin State
University at LaCrosse.

Registration fee is $10.00 and includes the
printed proceedings of the symposium. Advance
registration is required.

Program chairman is Dr. A. Erik Gundersen,
Department of Thoracic Surgery, Gundersen
Clinic, Ltd., of LaCrosse.

The course is approved for five hours post-
graduate credit by the American Academy of
General Practice.

Special guest speaker is Dr. Igor Shkotaba, Di-
rector of the Institute of Cardiology, Academy of
Medical Sciences, Moscow, U.S.S.R.

Auxiliary Plans
AMA-ERF Campaign

The Woman’s Auxiliary to the Mississippi State
Medical Association has begun working on its AMA-
ERF campaign for 1970-71. At a recent meeting in
the auxiliary’s office in the state headquarters build-
ing, Mrs. Curtis Caine of Jackson, center, auxiliary
president, discusses fund-raising plans with Mrs.
Doyle P. Smith of Jackson, at left, incoming chair-
man, and Mrs. Arthur E. Brown of Columbus who
has served as chairman for 12 years.

AMA President-Elect
Is State Native

Dr. Wesley Whitfield Hall, the new president-
elect of the American Medical Association, is a
native of Mississippi.

He is a brother of Dr. Toxey Hall of Belzoni
and Mrs. Elizabeth Stone of Shelby and a neph-
ew of Judge Toxey
Hall of Columbia.

Born in Lumberton,
Dr. Hall was the son
of Dr. and Mrs. Wes-
ley Hall. The family
moved to Ruleville in
1915 and later to Gun-
nison and Shelby. His
father was a member
of the State Board of
Health for 16 years
and served one turn
as president.

Dr. Hall received
his B.A. degree cum
laude from Mississippi College in 1926, studied
medicine at the University of Mississippi for
two years and got his M.D. degree from Tulane
University in 1930.

He served his internship and surgery residency
at the Baroness Erlanger Hospital at Chattanooga,
and then went into the practice of medicine and
surgery at Shelby.

In 1943 he was one of three Mississippians
elected a senior fellow of the American College
of Surgeons.

Dr. Hall moved to Reno, Nev., that year and
subsequently became secretary and then for sev-
eral years president of the Nevada Medical So-
ciety.

He has served for 24 years either as delegate
or member of the board of trustees of the AMA
and was chairman of the board for two years.

The surgeon has served as chief of staff at both
Reno hospitals, St. Mary’s and Washoe General
Hospital.

He spoke to the Mississippi State Medical As-
sociation at its 100th annual session in 1968 in
Jackson.

Dr. Hall’s son. Dr. Wesley W. Hall, Jr., a grad-
uate of the University of Mississippi School of
Medicine, completed his residency in surgery in
Denver in July. He has joined his father in the
practice of general surgery in Reno.

456

JOURNAL MSM A

Mr. Whitaker Selected
for USPHS Study

A Mississippian is contributing to the develop-
ment of nationwide programs that are designed
to improve patient care in hospitals and nursing
homes.

Harold H. Whitaker, supervisor of the Health
Insurance Unit of the State Beard of Health, has
been selected by the U.S. Public Health Service
to serve on a panel of specialists that will review
a course of study and 12 syllabi prepared for
professional personnel involved with the Medi-
care and Medicaid programs.

The materials were developed recently by Tu-
lane University, through contract with the USPHS,
as a part of a program to upgrade services in
hospitals, nursing homes and other facilities cer-
tified under Titles XVIII and XIX of the Social
Security Act.

Whitaker, with other members of the reviewing
panel, will be in New Orleans, July 14-16, audit-
ing a prototype course now in progress at Tulane
University and evaluating 12 short course train-
ing syllabi.

After modifications recommended by the panel,
the 6-week course, entitled ‘'Health Facilities Sur-
vey Improvement Program,” will be offered to
state surveyors through other universities in the
United States.

The in-depth training syllabi that the panel will
evaluate are designed to meet the needs of sur-
veyors, consultants, and health facility adminis-
trators.

Each syllabus covers a subject area related to
conditions that must be complied with by pro-
viders of health care under Medicare and Med-
icaid, such as physical environment, pharmaceu-
tical services, nursing service and dietary service.

Joining the State Board of Health in 1966,
shortly after it was designated as the survey and
certification agency for providers of health ser-
vices under Medicare, Whitaker assisted in selling
up the Health Insurance Unit and has served as
its supervisor for over four years.

Whitaker’s responsibilities were expanded in
early 1970 when the State Board of Health en-
tered an agreement with the Mississippi Medicaid
Commission to perform certification functions for
the Medicaid program.

A native of Clarksdale, Whitaker received his
B.S. degree in accounting from Mississippi State
University. He was engaged in hospital adminis-
tration for eight years prior to joining the State
Board of Health.

CPR Course Offers
Teacher-Training

A class of 16 instructors from across the state
were in Jackson for a Cardiopulmonary Resuscita-
tion Faculty Training Course, offered jointly by the
Mississippi Heart Association , Mississippi Regional
Medical Program and the University of Mississippi
School of Medicine. Taught by a team of three, par-
ticipants learned CPR techniques, as well as certain
legal aspects. At left. Dr. John Busey of Jackson ob-
serves while Dr. James M. Cooper of Tupelo , right,
practices on a resuscianne.

Family Practice to
Give Second Exam

The American Board of Family Practice will
give its second examination for certification in
various centers throughout the United States. The
examination will be over a two-day period on
February 27-28, 1971.

Information regarding the examination and el-
igibility can be obtained by writing:

Dr. Nicholas J. Pisacano. Secretary-Treasurer,
American Board of Family Practice. Inc., Uni-
versity of Kentucky Medical Center, Annex #2,
Room 229. Lexington. Kentucky 40506.

AUGUST 1970

457

HOUSE OF DELEGATES / Continued

association sources. We were most fortunate in
paying no closing costs other than a recording fee
of $6.

Insurance. Necessary additional insurance cov-
erage has been purchased, and we have had all
mechanical equipment inspected by an indepen-
dent safety engineer. The coverage includes na-
tural and fire hazard losses, liability, medical pay-
ments, and mechanical equipment. We have also
made the necessary adjustments in title insurance
to protect the association's additional investment.

Expression of the Board. The Board of Trust-
ees has commended the Building Committee and
all associated with the project. The new and
needed space is already contributing to greater
office efficiency, and the association has a valu-
able, appreciating investment in our building.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

We commend the Board and those who worked
actively in the building addition project. Our as-
sociation now has new and useful facilities for
the conduct of our affairs, and your committee
urges every member of the association to visit his
building and see this valuable asset. We approve
the project and recommend adoption of the re-
port.

The report of the reference committee was
adopted.

SUPPLEMENTAL REPORT “D'’ OF
THE BOARD OF TRUSTEES

Your Board of Trustees, acting as the interim
executive and governing body of your association,
feel that we must speak to you frankly and can-
didly. We have carefully considered the content
of this report and are unanimous in presenting it
to you. We support it fully and ask that you, the
House of Delegates, give it your most serious
consideration. We realize that some of the recom-
mendations are painful but, nonetheless, we feel
that medicine will suffer the consequences if we,
your elected officers, abdicate our responsibility
to you. We must lead every member to devote
himself personally and financially to meeting the
many crises facing medicine. We have come to
realize that we in medicine react to change but
we seldom initiate change on our own.

The Crisis. The 1968 Legislature took office
amid social, educational, and financial turmoil.
In addition to local problems, local action was
necessary to implement federal programs such as
Title XIX. At your direction we launched an ag-
gressive educational campaign to get Title XIX

implemented in Mississippi. Even though we
spoke clearly, we could not make our voices
heard in the Legislature. We failed completely
and Title XIX was not passed in the first bien-
nium. Our ineffectiveness was demonstrated again
when the Legislature placed an optometrist on
the State Board of Health in spite of our vigorous
opposition.

The Extraordinary Session of 1969 was called
to consider Medicaid along with other difficult is-
sues. We again offered ourselves as consultants to
the Legislature on this program of such vital con-
cern to medicine. In spite of our diligent efforts,
the program was written largely “without us.”
With certainty we did not lead in the enactment
of the law.

The first annual Regular Session of 1970
showed the widening cleavage between organized
medicine and the Legislature. Among the dam-
aging legislation introduced were bills to:

— Add a pharmacist to the State Board of
Health.

— License physical therapists and/or correc-
tive therapists without examination, thereby de-
stroying the four-year work of the medical and
physical therapy associations to secure a sound
law to protect the public.

— Provide that malpractice claims and those
for negligence against physicians may be ordered
paid by juries without corroborative medical evi-
dence.

— Add two dentists (for a total of three) to
the State Board of Health.

— Require the State Board of Health to grant
licensure to osteopaths by reciprocity.

— Create a new State Board of Health with
only one of nine members named by MSMA and
transferring present physician-members to a new
Board of Medical Examiners.

We expect no special or favored position with
the Legislature but we do desire fair treatment
and impartial hearings on matters relating to
health and medical care. Over the years there
have been many issues we have opposed but in
1970 we were attacked openly and we were
forced to expend our time and our substance in
fighting these threats.

Verbal excesses by some of the lawmakers re-
flected bitterness and animosity against the medi-
cal association. Late in February 1970. the diffi-
culties seemed to peak. Your leadership requested
a joint meeting with health committees of both
chambers and our mutual problems were openly
discussed. The message from the Legislators was
unmistakably clear. It is not enough for us to have
our staff carry messages, give written testimony

458

JOURNAL MSMA

and for them to make day to day contacts. The
senators and representatives asked for continual
communication with their constituent physicians.
We must commit ourselves in this connection.

After this meeting most of the damaging leg-
islation was put aside. Even so, we were told to
expect renewed onslaught in 1971. We were ad-
vised in writing that punishing legislation would
be introduced and likely passed unless we formu-
late more adequate handling of malpractice
claims and review. We were notified that our po-
sition against chiropractic is tenuous and passive
and that this cult would probably be licensed in
the future unless we formulated a positive pro-
gram against it. While the scoreboard looks good
in 1970, we must act decisively or anticipate seri-
ous and major reversals in the future.

On the positive side in 1970 we did manage to
have two measures passed.

— Professional Corporation Law.

— Increased fees for autopsies when ordered
by agencies of government.

Recommendations. We feel an intense person-
al commitment and financial sacrifice must be
made by all our members if we are to be success-
ful in meeting the challenge against medicine. To
have a positive program we must develop policy
positions before a session of the legislature meets.
We must initiate legislation when indicated.

An informed membership can effectively coun-
sel with their legislators. To keep the member-
ship fully informed on all legislative issues the
weekly legislative report should be sent to all
members of the association.

The legislative council should meet frequently
and not less than once monthly when the legisla-
ture is in session.

The Emergency Medical Care Unit must be
continued. There should be increased participa-
tion from the ranks of medicine to assure a Doc-
tor of the Day for every working legislative day.

An association executive must be at the capitol
each working day.

Our participation in AMPAC and MPAC
(Mississippi Medical Political Action Committee)
should be increased and billings to all members
under the policy previously adopted by the House
of Delegates as to its voluntary aspects be made.
We can also undertake to relieve volunteer phy-
sician-secretaries of component medical societies
of dues-billing burden with the new and addition-
al resources and in this way, we can increase the
efficiency of our revenue collections. The two so-
cieties now billing for PAC dues produce virtual-
ly two-thirds of our PAC members.

To finance this positive program a dues in-

crease is mandatory. In 1969, the House of Dele-
gates accepted a report that there would be a dues
increase in 1971. We have an even greater need
now. We therefore recommend a dues increase
to $100.00 annually. The $40.00 increase ear-
marked as follows: $10 for legislative and gov-
ernment relations, $10 for peer review and med-
ical service activities, $10 for cost-of-living in-
creases, and $10 for the building.

The Gauntlet. We have other challenges and
needs in addition to the legislative crisis. Medi-
cine is under attack in the halls of Congress, in
government programs and on the television net-
works. Specifically, we are challenged in legisla-
tion, public affairs, health care delivery, and peer
review. We have the facility, the physical hard-
ware and the staff core with capability and ex-
perience. We come to you, the membership, for
adequate financing and personal commitment. We
feel that the membership will give freely of their
time and their substance if we present the true
facts, unvarnished and of the whole cloth. If we
ask less from you, we fail in our position of trust.

We do not stand alone in the battle against in-
flation, government encroachment, and a climate
generally unfavorable to medicine. Other state as-
sociations and the AMA also have these prob-
lems. Most all of the state associations will have
dues to the $100 level by 1971. We must contin-
ue to support AMA as it works in our behalf at
the national level. If medicine’s house is divided
between the national and local level it is not like-
ly to stand.

We must have a viable peer review program or
be swallowed up by society and government med-
ical care programs. Can we equate the recom-
mended dues increase with devastating malprac-
tice legislation that would increase our premiums
many times? Can we equate continued full sup-
port of AMA against national compulsory health
insurance?

We have no guarantee that the positive pro-
gram outlined in this report will assure us victory,
but we do guarantee that no program will insure
the defeat of medicine as we know it today.

Conclusion. Let all understand — we are asking
you, the membership, for both financing and per-
sonal commitment. We must make up our minds
to work unceasingly and to pay our bills. While
we can guarantee no results our failure to act
will guarantee the consequences. Let us pick up
the gauntlet.

RESOLUTION NO. 5, FINANCIAL
NEEDS OF THE ASSOCIATION

Delta Medical Society Delegation: Resolved,
That this House of Delegates endorses the prin-

AUGUST 1970

459

HOUSE OF DELEGATES / Continued

ciple for the necessity of a dues increase for the
Mississippi State Medical Association as will be
proposed by the Board of Trustees at the 102nd
Annual Session.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

This report of the Board challenges every
member of the association to make a personal
commitment of time and money to his association
in behalf of the practice of medicine and im-
provement in the health care delivery system. We
consider this challenge important and urgent and
we approve the recommendations of the Board of
Trustees for a dues increase effective in 1971 to
$100 with amounts of the increase earmarked for
various activities, as recommended by the Board,
which we feel must be supported.

Of equal importance is the request for a per-
sonal commitment from every member of the as-
sociation. In our discussions, the Chairman of the
Council on Legislation, Dr. C. D. Taylor, Jr. of
Pass Christian, recommended that every physi-
cian in Mississippi be requested to give one day
each year of his time to legislative activities and
your reference committee feels that such a con-
tribution would be of immense value in our pro-
grams.

We commend this recommendation to the
membership and approve the report of the Board
of Trustees.

Resolution No. 5, submitted by the Delta Med-
ical Society, recognizes the need for increased
revenues, and we approve the resolution and
thank the society for its support in this matter.

In discussion. Dr. Lawrence W. Long on a
point of inquiry asked if AMA dues were still
compulsory in Mississippi, and the Speaker re-
plied in the affirmative. The report of the refer-
ence committee was adopted.

SUPPLEMENTAL REPORT “E” OF
THE BOARD OF TRUSTEES

Prior Actions. In 1958, the House of Dele-
gates accorded constitutional status to the Griev-
ance Committee whose purpose, according to our
By-Laws, “shall be to prevent or resolve misun-
derstandings, to clarify and adjust differences be-
tween physician and patient, and to assist in
maintaining high levels of professional deport-
ment already established by the Principles of
Medical Ethics.” The committee, consisting of one
member from each association district, has gen-
erally functioned in an appellate capacity and in

concert with grievance committees of component
medical societies.

In 1968, the House of Delegates approved a
program of Fee Review Committees for compo-
nent medical societies, and more recently, medi-
cal organization has adopted the concept of peer
review. This concept contemplates the functions
of a grievance committee and fee review com-
mittee, but it also makes clear that this is a task
for physicians.

The Board of Trustees believes that physicians
should make judgments on the quality of medi-
cal care and professional compensation therefor.
Under no circumstances should these tasks be
delegated or given by default to nonmedical
sources. We have witnessed, however, this trend
in and among insurance companies, voluntary
prepayment plans, and fiscal administrators for
government medical care financing programs.

Peer Review. The American Medical Associa-
tion strongly urges each state medical association
to establish a peer review program. The Board of
Trustees feels that we should make judgments in
this connection and prove ourselves worthy to
have our judgments accepted by medical care fi-
nancing sources. There is no greater challenge
before American medicine, and if we do not pre-
pare ourselves to perform these tasks and prompt-
ly undertake them, we may be assured that they
will be performed for us by others outside of med-
icine.

Many state medical associations, in response to
the AMA peer review program, have organized
themselves to carry out this important function
which ought to be performed only by physicians.
The Illinois State Medical Society has such a
program, and agreements have been made with
Medicare and Medicaid in that state for the med-
ical society to perform peer review. The govern-
ment payment sources have agreed to abide by
the society’s rulings.

This places great responsibility on medical or-
ganization, and such a program will require dedi-
cated and energetic physicians on peer review
committees and additional, competent staff. The
Board of Trustees has begun implementation of
this program with the appointment of a nine-
member Committee on Peer Review as an ad hoc
body. We propose to formalize this program into
a single state-wide endeavor with the broadest
possible participation, reservation of decision-
making to the local professional community
through component medical society committees,
and continual liaison with medical care financing
sources through our state association executive
staff.

460

JOURNAL MSMA

Objectives and Responsibilities. Peer review
perates essentially in two areas, scientific and
conomic. Scientifically, we are concerned with
le quality of medical care. We are interested in
le organization and delivery of care and avail-
bility and accessibility. We are just as interested
i problems of underutilization of health care re-
ources and facilities as we are in problems of
iverutilization, a wasteful drain on manpower, fa-
ilities, and funds.

Economically, peer review is a two-way street.
Ve are interested in fair and just compensation
ar quality services rendered, preferably under
he concept of usual and customary fees which
ve also have endorsed. We are equally concerned
vhen there is reason to believe that excessive
.‘harges have been made or when any charge re-
ates to what physicians may determine to be an
unnecessary service. We are interested in proper
md optimum and maximum benefit use of the
lealth care dollar, whether personal and out-of-
nocket or from tax (public) sources.

We feel that the time has come to gather the
unctions of grievance committee work, fee re-
view, and related activities under the single ban-
ner of peer review. We recommend that our asso-
:iation take the initiative in this respect and that
vve undertake these tasks with diligence and seri-
Dusness of purpose.

Program Formalization. The Board therefore
recommends that our previously announced poli-
cy relating to fee review be re-applied to peer re-
view and that Section 3, Chapter X. of the By-
Laws prescribing the Grievance Committee be re-
pealed and the following new section, identically
numbered, be adopted:

Section 3. Peer Review. The Committee on
Peer Review shall consist of nine members, one
from each Association district, appointed for
terms of three years each so as to provide for ap-
pointment of three members annually. Members
of this committee shall not simultaneously serve
on any disciplinary body of the Association or its
component medical societies. To this committee
shall be assigned the work of peer review, includ-
ing but not limited to resolution of differences
between patient and physician, review of the
quality of medical care, adequacy and/or reason-
ableness of fees, whether due or paid from pri-
vate or public sources, utilization of health care
resources, and liaison with private and public
sources of medical care financing. The committee
is empowered to encourage a response from any
member of the Association in writing or by per-
sonal appearance, authority to initiate investiga-
tions on its own motion, and authority to file

charges against a member in the name of the
committee before the Judicial Council or a disci-
plinary body of a component medical society.
Under no circumstances, however, shall the Com-
mittee on Peer Review exercise any disciplinary
function nor shall it be empowered to alter the
status or standing of any member. The committee
shall be empowered to prescribe its rules of opera-
tion which shall not be in conflict with the policies
or By-Laws of the Association.

Staff Support. For the committee to function
effectively, it must enjoy substantial staff support
in assembling quantities of data, in the conduct of
liaison with insurance, prepayment, and admin-
istrative organizations, and in the preparation of
communications and reports. Mindful of this
need, the Board has provided for a qualified ex-
ecutive with adequate research and secretarial
assistance and direct access in reporting to the
Executive Secretary. The staff will also carry out
the wishes and directions of the committee in
communicating with counterpart committees of
component medical societies.

Concomitant Recommendation. The Board has
reported that the Legislature has advised the as-
sociation in writing that unless a review activity
is made available to patients, especially with ref-
erence to medicolegal problems, we may expect
enactment of a measure which would permit pay-
ment of malpractice or negligence awards by
juries without corroborative medical evidence.
The Board recommends that each major medical
community and component medical society reac-
tivate physician-attorney committees so that the
work of peer review may be continually com-
municated to the legal profession.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

The Board has initiated a peer review program
at state level and in this report recommends that
this program be extended to every component
medical society of the association.

We recognize the importance and timeliness of
a valid peer review system and its importance as
an instrument of self-regulation. Your committee
points out that peer review is in no way punitive
but rather is educational and corrective.

We are pleased to see that the Board has
planned extensive staff support for this program,
and we recommend that the system of peer re-
view as outlined in the report be instituted at the
earliest possible time.

The report of the reference committee was
adopted.

AUGUST 1970

461

HOUSE OF DELEGATES / Continued

REPORT OF THE COUNCIL
ON CONSTITUTION AND BY-LAWS

In its supplemental report on peer review, the
Board of Trustees recommends repeal of Section
3, Chapter X of the By-Laws, presently provid-
ing for the Grievance Committee, and substitut-
ing therefor a provision for establishing a Com-
mittee on Peer Review, which will consist of nine
members with terms of three years each.

The proposed amendment prescribes the duties
of the committee. We approve this proposal and
recommend that the following be added at the
end of the new section: “The committee shall al-
so encourage and assist component medical so-
cieties in forming Committees on Peer Review at
the local level.”

We recommend adoption of this amendment to
the By-Laws, as amended.

The report of the council, acting as a reference
committee, was adopted.

SUPPLEMENTAL REPORT “F” OF
THE BOARD OF TRUSTEES

Resolution No. 6. At the 101st Annual Session
in 1969, the House of Delegates adopted Resolu-
tion No. 6, subject: Professional Corporations,
introduced by the West Mississippi Medical So-
ciety. The resolution recommended association
approval of incorporation by physicians in an ef-
fort to achieve greater tax equity and to enjoy
business privileges long available to other en-
deavors. The resolution directed that necessary
legislation be drafted and introduced in the 1970
Regular Session of the Mississippi Legislature.

Enactment. The association-sponsored measure
was House Bill 48, introduced in our behalf by
Hon. Fred Lotterhos of Hinds County. We re-
ceived valuable guidance and assistance by the
House Committee on the Judiciary to which the
bill was referred and especially from the chair-
man, Hon. H. L. Merideth of Washington Coun-
ty. The association presented testimony in sup-
port of the measure on three occasions.

The enactment amends Section 5390-42 of the
Mississippi Code of 1942, Annotated. It defines
“professional service” as a personal service to the
public which “requires as a condition precedent
the obtaining of a license or other legal authoriza-
tion and which prior to the passage of this act
and by reason of law could not be performed by a
corporation.”

We were also successful in securing the privi-
lege of incorporation by solo practitioners, as re-
quested by a floor amendment to Resolution No.
6 at the 101st Annual Session.

Benefits. Not every physician will find it prof-
itable or even economical to incorporate, and the
Board of Trustees advises members to consult le-
gal counsel and personal auditors (C.P.A.’s) as
to their individual circumstances, potential ad-
vantage, and possible disadvantage. The Board
also advises that financial vehicles be chosen with
care from among the many reliable sources avail-
able. Benefits available are many and substan-
tial, because the Mississippi enactment confers
upon professional incorporators the benefits of the
Mississippi Business Corporation Act or that re-
lating to conventional corporations. Among these
benefits are:

— Deferred compensation (retirement) plans
qualified under Section 401(a) of the Internal
Revenue Code of 1954, permitting full deduction
from federal taxes of contributions to such plans.

— Progressive vestment under such plans
where the beneficiary shall have been deemed to
have received no income until actual payment of
benefits.

— Group life insurance with premiums fully
deductible.

— Death benefits up to $5,000 without taxa-
tion either to the professional corporation or to
recipients.

— Sick pay with tax exclusions up to $100 per
week.

— Workmen's Compensation, exclusion from
gross income of travel expense, meals, and lodg-
ing under certain circumstances, and other mis-
cellaneous benefits.

Expression. The Board of Trustees expresses
satisfaction over the success of this project and
expresses appreciation to the membership, the
Legislature, the Governor, and all concerned with
the full and final implementation of Resolution
No. 6.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

In response to Resolution No. 6 adopted at the
101st Annual Session in 1969, the association
sponsored legislation during the 1970 regular ses-
sion to amend appropriate statute to provide for
professional corporations for professional individ-
uals.

The Board informs us that the sound and use-
ful law was enacted and we express our appreci-
ation to the Legislature for this enactment.

We caution all members of the association who
contemplate incorporation to consult with tax ad-
visers and legal counsel.

The report of the reference committee was
adopted.

462

JOURNAL MSM A

REPORT OF THE SECRETARY-TREASURER

Dr. Walter H. Simmons: Duties and Responsi-
bilities. As an elected general officer of the asso-
fiation, your Secretary-Treasurer is charged with
such duties as ordinarily devolve upon the secre-
tary of a corporation by law, custom, and usage.
Additionally, he is the constitutional designee as
chairman of the Council on Scientific Assembly
and member ex officio of councils and committees.

Membership. The modest but encouraging
growth trend in membership continued through
1969 with an increase of about 5 per cent. The
total as of Dec. 31, 1969, is:

1,331 paid Active members
68 Emeritus members
46 members exempt from dues other
than Emeritus

This is a total of 1,445 for 1969, representing
a net gain of 66 members over 1968. The total
for 1970 membership as of May 5 is:

1,311 paid Active members
68 Emeritus members
37 members exempt from dues other
than Emeritus

Fiscal Reporting. In accordance with usual
practice, your Secretary-Treasurer submits a con-
densed statement of your association’s fiscal con-
dition as an attachment to this report. The Coun-
cil on Budget and Finance has reviewed the re-
port of audit, fiscal records, and has reported to
the Board of Trustees in this connection. An
overall budget of $215,741 has been recommend-
ed to and approved by the Board of Trustees,
and a copy of the budget is attached to this re-
port. This amount is exclusive of funds which the
association will expend in payment of professional
fees and authorized benefits under the Civilian
Health and Medical Program of the Uniformed
Services (CHAMPUS) which will be reimbursed
to the association by the Department of Defense.
It is projected that these funds will amount to
about $1.8 million in 1970.

Constitutional Duties. Your Secretary-Treasur-
er, as an ex officio member of councils and com-
mittees, meets with various official bodies of the
association and sits with the Board of Trustees as
a general officer. Activities related to service as
chairman of the Council on Scientific Assembly
have been reported separately.

MISSISSIPPI STATE MEDICAL ASSOCIATION
CONDENSED STATEMENT OF
FINANCIAL CONDITION
DECEMBER 31, 1969

ASSETS

Current Assets
General Fund

Cash on deposit . . $137,208 $

Due, Journal advertisers . 4,591

Due, CHAMPUS 38,499

Other receivables 704

Prepaid expenses 810 181,812

Fixed Assets

Building and equipment, less de-
preciation 172,403

Land 13,605 186,008

Other Assets

Deferred CHAMPUS expenses 3,340

Refundable deposits 25 3,365

Total book assets $371,185

LIABILITIES AND NET WORTH
Current Liabilities

Accrued expenses $ 4,796 $

Construction contract payable . 24,761

AM A dues in transit 16,670

AMA dues pending 245

CHAMPUS capitalization 100,000

Current mortgage 14,808

Accrued taxes 4,499

Accrued interest payable 908

Accounts payable, CHAMPUS . 108 166,795

Long Term Liabilities

Mortgage 52,732

Deferred income 13,766 66,498

Net Worth 137,892

Total liabilities and net worth $371,185

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

Your reference committee appreciates the re-
port of the Secretary-Treasurer, Dr. Walter H.
Simmons of Jackson. We are encouraged by the
stability and modest growth of membership and
we commend Dr. Simmons for his work in our
behalf, both as Secretary-Treasurer and as Chair-
man of the Council on Scientific Assembly.

We approve the report and recommend its
adoption by the House of Delegates.

The report of the reference committee was
adopted.

REPORT OF THE COUNCIL ON BUDGET

AND FINANCE

Report of the Secretary-Treasurer. We have
considered the fiscal portion of the report of the
Secretary-Treasurer, and we have examined the
operation of the association with respect to all fis-
cal activities, including the report of the indepen-
dent certified public accountant. The findings are
to the satisfaction of your council. Prior to this
annual session, we have met for this purpose and
conferred with the Board of Trustees. We have
determined that all accounts, receipts, and dis-
bursements are regular, proper, and authorized.

Association Budget. We have considered the
1970-71 budget for operation of your association,
and we have conferred with the Board of Trust-
ees who have approved our recommendations.
Each item in the budget has been carefully eval-
uated as to necessity and adequacy. We recom-
mend a total budget of $215,741.00 for general
operation of all activities in departments of the as-

AUGUST 1970

463

HOUSE OF DELEGATES / Continued

sociation, including production of your Journal.
The overall budget is exclusive of professional
fees for the CHAMPUS Program which are re-
imbursed to the association by the Department of
Defense. For 1970, we estimate that this amount
will be $1.8 million. We recommend adoption of
the budget as being a realistic minimum for the
continued effective operation of your association.

Insurance and Safeguards. We have examined
a survey of insurance owned by the association
on its properties and against certain liabilities
which conceivably could be incurred, and we find
it adequate. We have also examined the addition-
al insurance which has been obtained on the
building addition, including increased title insur-
ance and insurance on all mechanical installations
which have been inspected by an independent
safety engineer. Suitable safeguards for disburse-
ment procedures, the handling of incoming funds
as recommended by our certified public account-
ant, and proper safeguarding of records have
been provided and each has been examined by
your council. We find these to be adequate and
sufficient for our needs.

Service to Component Medical Societies , Your
council has determined that the central office is
able to offer a new service to component medical
societies of the association with reference to mem-
bership. Effective this year and for the 1971
membership year, the central office will prepare
statements and bill physicians directly for com-
ponent society, state association, AMA dues and
voluntary AMPAC and MPAC dues, furnishing
a postage-paid, return envelope with the billing.
We believe this will add greatly to the efficiency
of our dues collections and that it will ease a great
burden from volunteer physician-secretaries of
component medical societies.

No billing will be made unless clearance has
been obtained from the component medical so-
ciety.

The report of the council was adopted.

REPORT OF THE EXECUTIVE SECRETARY

Mr. Rowland B. Kennedy: Scope of Report.
Your Executive Secretary, under the By-Laws,
reports to the Board of Trustees, and as such has
submitted about 70 written reports during the
1969-70 association year. The present report is
one of highlights and of the headquarters staff. It
is purposely abbreviated to avoid any lengthy du-
plication or any discussion of association policy.

Executive Staff. With authority from the Board
of Trustees, the staff was reorganized in June

1969 into working departments. A new Executive
Assistant was appointed and assigned general ac
counting and internal management duties, am
the Department of Medical Care Plans was ex
panded to accommodate the growing CHAMPUJ
program which increased more than 50 per cen
in 1969. We were also fortunate in securing <
journalism graduate to serve as Editorial Assistant I
for your Journal.

Since the 1969 annual session, the staff hae
been expanded by four, and more recently, the
Board has authorized appointment of a third ex-
ecutive in an effort to cope realistically witf
growing challenges in legislation and other critica1
activities. We remain understaffed for assignee
and necessary duties.

We can, however, measure improvements anc
results as the staffing pattern becomes more real-
istic. Your Executive Secretary has recommend-
ed that further additions be authorized by the!
Board in the interest of association programs and
support for official bodies.

Legislation. Two sessions of the Legislature
have been conducted since the 1969 annual ses-
sion, and the interests of physicians and medicine!
are frequently at stake in pending laws and pro-
grams. The Board has concurred in a proposal to!
intensify our legislative communications to all;
members. Virtually all additional staff recom-s
mended will serve in legislative activities and ini
medical service programs.

Building Addition. The staff was privileged to
serve in a coordinating capacity with the Build-
ing Committee in the urgently needed building
expansion project. We deeply appreciate the ad-
dition which was essential to basic association
services and support of official programs and ac-
tivities. The refurbishing of your original 1 4-year- !
old building concomitantly with the construction
of the addition has given the association a valu-
able working facility as well as a sound invest-
ment.

Workload and Service Potential. With a well-
trained and experienced staff core, we have the
capability of furnishing needed support for grow-
ing responsibilities and challenges in activities.
The past year was a difficult one for your staff,
because no previous year required more produc-
tivity in legislation, government relations, associ-
ation programs, medical care plans administra-
tion, or in our share in the construction project.

We stand ready to offer the membership ad-
ditional services, and we are uniquely situated to
do so with core experience, data processing hard-
ware, more adequate office facilities, and updat-
ed equipment. Of particular value is the physi-

464

JOURNAL MSMA

dans’ data management service which can be
furnished much less expensively than comparable
commercial services. We invite your appraisal of
this proposed service in the Technical Exhibit of
the present annual session.

The Board has recognized that we have special
need for executives, and none need be reminded
that the years of the ’70’s will try sorely the ca-
pacity of the association to carry out the wishes
and objectives of the membership.

Personal Expression. The new association year
will mark my 20th as your Executive Secretary.
The decade ahead will be difficult, but your ex-
ecutive staff pledges its best efforts to serve you in
meeting the challenge to deliver more and better
medical care under our private system. I am
deeply grateful to the Board of Trustees, general
officers, official bodies of your association, and to
the component societies for the opportunity of
working in your behalf.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

The committee is pleased with the report of the
Executive Secretary and would like to take this
opportunity to recognize the 20th anniversary of
his service to the association and the excellence
of his performance in the various aspects of his
duties during all these years. We remind the
House of Delegates and the Board of Trustees of
his statements concerning the work load of his
staff, and we commend them for emulating his
example of excellence.

Applause from the House of Delegates was
given the report of the reference committee on
the Report of the Executive Secretary, and the
report was adopted.

REPORT OF THE THE COMMITTEE

ON AMA-ERF

Dr. Raymond F. Grenfell: Organization and
Duties. Your Committee on the American Medi-
cal Association Education and Research Foun-
dation is an ad hoc body of the House of Dele-
gates. Its principal duty is to encourage members
of the association and the Woman’s Auxiliary to
support AMA-ERF with voluntary, tax-deducti-
ble contributions. Every dollar received goes to
medical education or research, and the donor
may even earmark his gift for a particular institu-
tion. No administrative expense for the conduct
of fund-raising campaigns comes from gifts: At
national level, AMA pays the full cost of founda-
tion administration, and at state level, the associ-
ation pays for all solicitation costs.

1969 Contributions. Last year, our total gift to

the University of Mississippi School of Medicine
and Medical Center was $12,099.97, represent-
ing $9,410.17 contributed by Mississippi physi-
cians and Auxiliary members. The remainder
represents undesignated gifts which are equally
distributed among all accredited four-year medi-
cal schools by AMA-ERF.

1970 Program. Our total contributions declined
in 1970, and we have presented the University
with $11,102.40, representing $8,615.94 ear-
marked for the school and $2,486.46 in the un-
designated foundation fund distribution. This
year our per capita physician gift remained high-
er than those in our four neighboring states:

State No.M.D.’s Total PerM.D.

Alabama 2,122 $ 630.00 $ .30

Arkansas 1,288 995.00 .77

Louisiana 2,170 3,685.00 1.69

Mississippi 1,429 6,330.00 4.43

Tennessee 2,891 8,888.00 3.09

Our Auxiliary gave $2,682.56 in the 1970
campaign, a commendable increase over the 1969
total of $1,750.43. We continue to work with the
University in solicitation mailings, and we thank
our president, Dr. James L. Royals, for his sup-
port in this work. We urge every association and
Auxiliary member to contribute next year.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

Your reference committee considered the an-
nual report of our Committee on AMA-ERF,
and we are extremely gratified to note that Mis-
sissippi physicians continue to give more on a per
capita basis to medical education than physicians
in Arkansas, Louisiana, Tennessee or Alabama.
We encourage this program and ask that the as-
sociation continue to support it by solicitation of
all physicians for voluntary contributions to med-
ical education. We approve the report of this
committee and thank the members for their good
service to medical education and to our associa-
tion.

The report of the reference committee was
adopted.

AUXILIARY OFFICERS

The Speaker presented Mesdames Louis C.
Lehmann of Natchez, 1969-70 President of the
Woman's Auxiliary to the Mississippi State Med-
ical Association, and Curtis W. Caine of Jackson,
1970-71 President, who addressed the House of
Delegates.

1970 MSMA-ROBINS AWARD

President Royals presented the 1970 Mississip-
pi State Medical Association-Robins Award to
Dr. W. J. Aycock of Calhoun City for outstand-

AUGUST 1970

465

HOUSE OF DELEGATES / Continued

ing community service by a physician. Mr. Wil-
lard Duvall of New Orleans, district manager for

A. H. Robins Co., assisted Dr. Royals in the pre-
sentation.

SCIENTIFIC EXHIBIT AWARD

Dr. Walter H. Simmons, chairman of the
Council on Scientific Assembly, presented the
Aesculapius Award, an honorarium of $500, to
Dr. James P. Spell of Jackson for the best scien-
tific exhibit by a member. Dr. Spell’s exhibit was
“Systemic Clues to Occult Cancer.”

RESOLUTION NO. 1, IN MEMORIAM

Dr. Walter H. Simmons: Whereas, There are
absent from among our numbers 21 members
who have been called by Divine Providence since
the 101st Annual Session; and

Whereas, Although we are grieved upon the
passing of these beloved colleagues and friends,
we are inspired by their lives of service and pro-
fessional attainment; and

Whereas, This expression of our grief, deep
affection, and respect should be recorded perma-
nently among official records of the Mississippi
State Medical Association, now therefore, be it
Resolved, That this House of Delegates does
mourn the passing of the following esteemed col-
leagues:

John C. Adams, Greenwood, August 28, 1969
William H. Anderson, Booneville, May 9, 1969
George G. Armstrong, Sr., Houston, November
17, 1969

John R. Bane, Jr., Jackson, October 26, 1969
James E. Coe, Lambert, June 18, 1969
J. Kenneth Cooke, Houston, Texas, February 11,
1970

James H. Fox, Jackson, January 8, 1970
Thomas W. Frazier, Crawford, May 11, 1969
Edward L. Gilbert, DeKalb, July 11, 1969
James C. Green, Tupelo, December 3, 1969
Percy P. Haslitt, Ocean Springs, May 19, 1969
Isaac C. Knox, Sr., Vicksburg, September 1, 1969
Luther L. McDougal, Tupelo, December 12,
1969

Junius K. Oates, Laurel, July 22, 1969

B. B. O’Mara, Biloxi, May 24, 1969

Luther B. Otken, Greenwood, November 25,
1969

Daniel H. Raney, Mattson, November 27, 1969
Milton H. Robertson, Corinth, March 13, 1970
George T. Warren, Brookhaven, May 30, 1969
Oliver B. Wingo, Sardis, January 31, 1970
Maurice R. Wingo, Pass Christian, October 25,
1969

466

ACTION OF THE HOUSE OF DELEGATES

Without objection, Resolution No. 1 was acted
upon without referral and adopted by the House
of Delegates with all present standing in silent
tribute.

RESOLUTION NO. 2, AMENDMENT
OF ABORTION LAWS

Dr. J. Purves McLaurin, Jr.: Whereas, Mis-
sissippi law prohibits abortion except where con-
tinuation of the pregnancy poses a threat to the
life of the patient or where the pregnancy results
from forcible or statutory rape, and

Whereas, A significant number of states have
recognized that abortion may be lawfully per-
formed when one of the foregoing conditions pre-
vails or when the pregnancy results from incest,
when continuation of the pregnancy poses a
threat to the health of the patient, and/or when,
in cognizant medical opinion, there is a probabil-
ity that the infant will be born deformed, and

Whereas, The American Medical Association
and the American College of Obstetricians and
Gynecologists have respectively approved abor-
tion under any one of the foregoing conditions,
and

Whereas, There is strong opinion among cit-
izens of the state and the medical profession that •
the Mississippi law should be amended to reflect
these additional socially and medically acceptable
conditions under which this procedure may be
performed, now, therefore, be it

Resolved, That the policy of the Mississippi
State Medical Association be that abortion should ;
not be performed except when ( 1 ) the pregnancy
results from forcible or statutory rape or from in-
cest, (2) continuation of the pregnancy poses a
threat to the life or health of the patient, or (3)
when, in cognizant medical opinion, there is a {
probability that the infant will be born deformed |
and that the procedure be undertaken by a physi-
cian only ( 1 ) when consultation has been ob-
tained in writing from another physician and (2)
the procedure is performed in a licensed hospital,
and be it further

Resolved, That this policy in no way alters the
association’s long-standing view that criminal or
illicit abortion be vigorously prosecuted under ap-
plicable criminal law, and be it further

Resolved, That amendments in existing Mis-
sissippi law be sought to implement this policy
during the 1971 Regular Session of the Mississip-
pi Legislature.

REPORT OF THE REFERENCE COMMITTEE
ON MEDICAL PRACTICES

This resolution proposes that the policy of the
association be that abortion should not be per-

JOURNAL MSMA

formed except when ( 1 ) the pregnancy results
:rom forcible or statutory rape or from incest,
(2) continuation of the pregnancy poses a threat
to the life or health of the patient, or (3) when,
in cognizant medical opinion, there is a probabili-
ty the infant will be born deformed and the pro-
cure be undertaken by a physician only ( 1 )
vhen consultation has been obtained in writing
from another physician and (2) the procedure is
Derformed in a licensed hospital.

This proposal in no way alters the association’s
ong-standing policy that criminal or illicit abor-
tion be vigorously prosecuted under the applica-
ble criminal law. We approve this resolution and
recommend its adoption by the House of Dele-
gates. We further request that necessary legisla-
tion be drafted and submitted to the 1971 regular
session.

The report of the reference committee was
adopted.

RESOLUTION NO. 3, LIMITED
LICENSURE OF PHYSICIANS

Drs. Richard C. Fleming, Jr., and William M.
Gillespie, Jr.: Whereas, There presently exists a
serious shortage of physicians in the state of Mis-
sissippi, with a doctor-population ratio of 1 : 1,400
as compared with the national average of 1:700,
and

Whereas, The physician shortage is especially
acute in many of the State-operated institutions —
medical and surgical (charity) hospitals, mental
hospitals, mental retardation school, tuberculosis
sanitarium, county public health departments,
and penal institutions, and

Whereas, In an attempt to provide more ade-
quate medical and health care to the patients
served by such State-operated institutions, it has
been necessary for many years to employ the ser-
vices of certain carefully-selected and competent
Foreign Medical Graduates, who are not eligible,
due to lack of U. S. Citizenship and/or non-pos-
session of ECFMG certification, to be examined
for full Mississippi medical licensure, and

Whereas, The impending application of most
of these same State-operated institutions to par-
ticipate in Medicare and Medicaid requires that
all physicians providing care in these institutions
be licensed, in some form, to practice medicine
by the State of Mississippi, and

Whereas, Many other States in this country
already have provision for the granting of limited
or institutional licensure, for practice restricted to
the institutions of employment, and

Whereas, There is, at present, no provision
for any form of limited or institutional licensure
to practice medicine in a restricted capacity in the
State of Mississippi, now therefore, be it

Resolved, That the Mississippi State Medical
Association, through affirmative action of its
House of Delegates, requests the State Board of
Health to expedite the establishment of a cate-
gory of limited or institutional licensure, annually
renewable, for certain carefully selected foreign
medical graduates on the recommendation of the
superintendent and/or board of trustees of the
state institution, the component medical society
in whose professional jurisdiction the institution is
located, the state medical association Trustee in
that district, and the medical member of the State
Board of Health in that Public Health District.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

This resolution asks that certain carefully se-
lected foreign medical graduates be given limited
licensure in order to serve in certain institutions
operated by the State of Mississippi. We concur
in this resolution, recommending only a minor
change in the resolving clause. We recommend
that the resolving clause be amended as follows:

“ Resolved , That the Mississippi State Medical
Association through informative action of its
House of Delegates request the State Board of
Health to expedite the establishment of a category
of limited institutional licensure, annually renew-
able, for certain carefully selected foreign medi-
cal graduates on recommendation of the superin-
tendent and the board of trustees of the State in-
stitutions, the component medical society in whose
professional jurisdiction the institution is located,
the state medical association Trustee in that dis-
trict, and the medical member of the State Board
of Health in that public health district.”

We feel that this will assist in alleviating to
some extent the shortage of physicians in this
state and meet the challenge of certain medico-
legal urgencies which we face.

Your reference committee recommends the
adoption of Resolution No. 3, as amended.

The report was discussed by Drs. Dewitt Ham-
rick of Corinth, H. C. Ricks, Sr., of Jackson,
C. D. Taylor, Jr., of Pass Christian, James Grant
Thompson of Jackson, Guy T. Vise of Meridian.
President Royals reported receiving a telegram
stating that the Mississippi Psychiatric Society op-
posed the resolution.

The report of the reference committee was
adopted.

RESOLUTION NO. 4, STATUTORY
STANDARDS OF PRACTITIONERS

Dr. Lawrence W. Long: Whereas, The Mis-
sissippi State Medical Association is dedicated to
the conservation and protection of the health of
all citizens, and

Whereas, The cult of chiropractic constitutes

AUGUST 1970

467

HOUSE OF DELEGATES / Continued

a hazard to rational health care because it is a
false dogma based on a totally unscientific prem-
ise and whose practitioners rigidly adhere to their
irrational, unscientific beliefs, and

Whereas, The State of Mississippi, through
the wisdom of its Legislature, has consistently re-
jected the repeated demands of the cult of chiro-
practic to be licensed and accorded the sanction
and badge of respectability by the state, and
Whereas, The position of the Mississippi State
Medical Association is substantiated by an over-
whelming preponderance of documented, scientif-
ic evidence and by the formal findings and dec-
larations of the United States Government, and
Whereas, In this era of scientific advance-
ment there cannot be permitted to exist a double
standard of health care for the citizens of Missis-
sippi, one scientific and one cultist, now, there-
fore, be it

Resolved, That the House of Delegates of the
Mississippi State Medical Association directs that
whatever legislation is necessary be drafted and
introduced in the next Regular Session of the Mis-
sissippi Legislature to require that chiropractors
and any other practitioners who hold themselves
out as competent to diagnose and treat human
disease must meet the same standards of educa-
tion and training as doctors of medicine.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

This resolution offers a positive program for
combating the cult of chiropractic in Mississippi.
We heard excellent testimony in this connection,
and we are grateful for the presence of Mr. Doyl
Taylor, Director of the AMA Department of In-
vestigation, Chicago, who came to our convention
to assist us in this respect.

The Legislature has stated that unless the as-
sociation adopts a positive program on chiroprac-
tic that we are likely to have a licensure law in
the immediate future. We feel that this is a posi-
tive program, and it roughly approximates the de-
cision handed down by the U. S. Supreme Court
in the case of England v. Louisiana. This would
achieve, in effect, in statute what was achieved
by court decree in the Louisiana case.

We earnestly recommend that the Board of
Trustees and the Council on Legislation work
vigorously to implement this resolution in the
1971 regular session of the Mississippi Legisla-
ture. We approve the resolution and urge all
members to support the implementation.

The report of the reference committee was
adopted.

RESOLUTION NO. 6, EXEMPTION
FROM DUES BASED ON AGE

Dr. Walter H. Simmons: Whereas, The By-
Laws of the American Medical Association pro-
vide that a member, upon request, may be exempt
from dues for life when, on January 1 of the year
for which the exemption is to become effective,
he has attained the age of 70, and

Whereas, The By-Laws of the Mississippi
State Medical Association, while providing many
and liberal bases for exemption from dues but
which provide no basis for such exemption by rea-
son of having attained age 70, and

Whereas, It is fitting and appropriate that
loyal members of the association, upon attain-
ment of age 70, be recognized by relief from dues
upon request and that there be a parallel basis for
such exemption with that of the American Medi-
cal Association, now, therefore, be it

Resolved, That Section 4(a), Chapter I, By-
Laws of the Mississippi State Medical Associa-
tion, is amended to add at the end of the section:
“Members who shall have attained age 70 and
who have been active members of the association
for any 10 consecutive years may, upon request,
be exempt from dues for life effective January 1
after the 70th birthday, and such exemption shall
continue so long as the member continues in
good standing in his component medical society.”

REPORT OF THE COUNCIL ON
CONSTITUTION AND BY-LAWS

The purpose of this resolution is to bring into
agreement certain provisions relating to active
membership between the state medical associa-
tion and AMA.

To accomplish this purpose, it is necessary to
amend Section 4(a), Chapter I of the By-Laws to
provide that “members who shall have attained
age 70 and who have been active members of the
association for any ten consecutive years may up-
on request be exempt from dues for life effective
January 1, after the 70th birthday and such ex-
emption shall continue so long as the member
continues in good standing in his component med-
ical society.”

We approve this amendment and recommend
its adoption.

The report of the council, acting as a reference
committee, was adopted.

RESOLUTION NO. 7, BURDENS OF
MEDICAID UPON PHYSICIANS

Dr. Norman W. Todd: Whereas, The Missis-
sippi State Medical Association supported enact-
ment of a Medicaid program in its commitment
and desire to continue to render the best possible

468

JOURNAL MSM A

medical services to all citizens of our state, and

Whereas, This program is administered and
directed by a statutory commission of the State of
Mississippi which is duly empowered to prescribe
regulations and administrative practices, and

Whereas, The Mississippi Medicaid Commis-
sion has published a Physicians’ Manual contain-
ing regulations and administrative requirements
which place burdensome and time-consuming pa-
perwork tasks upon physicians in practice, and

Whereas, Claims forms prescribed are need-
lessly complex, requiring employment of addition-
al clerical personnel in physicians’ offices, and
procedures for securing professional compensation
for care of Old Age Assistance recipients under
Medicare and Medicaid are unrealistically com-
plicated and costly in time and money to prac-
titioners, and

Whereas, Payment services under Medicaid
are excessively slow and uncertain, now, there-
fore, be it

Resolved, That the Mississippi State Medical
Association, while reaffirming its commitment to
render the best possible medical services to all
citizens, does protest and condemn the excessive-
ly burdensome regulations and requirements of
the Mississippi Medicaid Commission, does call
for elimination of these bureaucratic measures
which contribute nothing to medical care, and
does call for simplification of paperwork associ-
ated with the filing of claims and for payment
of such claims within reasonable periods of time.

REPORT OF THE REFERENCE COMMITTEE
ON MEDICAL PRACTICES

This resolution points out that the Medicaid
Program requires extensive use of complex forms,
resulting in paperwork burdens upon practition-
ers.

We approve the resolution but recommend
adoption of the following substitute resolving
clause:

Resolved, That the Mississippi State Medical
Association while reaffirming its commitment to
render the best possible medical services to all
citizens does protest the excessively burdensome
regulations and requirements of the Mississippi
Medicaid Program, especially the amount of pa-
perwork associated with claims filing, and does re-
quest that forms be simplified and clarified by
the commission by December 31, 1970, and be it
further

Resolved , That Old Age Assistance patients be
served by submission of a single claim to be Part
1-B, Medicare carrier which, in turn, would gen-
erate the necessary claim for the Medicaid Pro-
gram, and be it further

Resolved, That the association does offer its
services to the commission in achieving these
goals to improve the program and to lessen bur-
dens upon practicing physicians.”

Your Reference Committee recommends ap-
proval of the resolution as amended.

Dr. Clyde A. Watkins of Sanatorium moved to
amend the substitute resolving clause by insert-
ing the words “board of trustees of the” immedi-
ately following the words “does offer its services
to the” in the third “resolved” and the motion
was seconded by Dr. Frank M. Davis of Corinth.
The motion to amend was adopted, and the main
motion was adopted as amended.

RESOLUTION NO. 8. MEDICAL
STUDENT MEMBERSHIP

Dr. M. Beckett Howorth, Jr.: Whereas, The
Mississippi State Medical Association proudly ac-
cepts its responsibilities to medical education and
to the medical students who are our next profes-
sional generation, and

Whereas, The AMA House of Delegates has
requested each state medical association to pro-
vide a degree of membership for medical stu-
dents, and

Whereas, The Board of Trustees of the asso-
ciation has approved this proposal, as has at least
one component medical society of the association,
the North Mississippi Medical Society, now,
therefore, be it

Resolved, The Mississippi State Medical Asso-
ciation does establish a degree of membership for
medical students which shall be dues-free, that
said students shall be regularly enrolled in a med-
ical school approved by AMA which is located
in Mississippi, that application for membership
shall be submitted to the association, that a spe-
cial component shall be provisionally created and
provisionally chartered by the Board of Trustees
as regards the University of Mississippi School of
Medicine and such component shall be designat-
ed the University Medical Society whose mem-
bers may conduct their own society affairs under
the Constitution and By-Laws, including the elec-
tion of their own officers and voting delegates to
the Mississippi State Medical Association, and
that the Board of Trustees shall implement this
resolution, taking such additional actions as are
deemed necessary to fulfill its purpose, and be it
further

Resolved, That this resolution be implemented
without amendment to the By-Laws at this time,
pending amendment of the AMA By-Laws as to
the student membership and that criteria for
membership prescribed in MSMA By-Laws re-
lating to doctors of medicine may be waived to

AUGUST 1970

469

HOUSE OF DELEGATES / Continued

the extent necessary to accomplish these purposes
for student membership by the Board of Trustees.

REPORT OF THE REFERENCE COMMITTEE
ON REPORTS OF OFFICERS AND
BOARD OF TRUSTEES

This resolution proposes that a degree of mem-
bership be created for medical students in Mis-
sissippi and provides for their participation in the
work and affairs of our association. Your Refer-
ence Committee feels that this resolution and the
proposal have great merit, and we approve the
establishment of a degree of membership for med-
ical students in accordance with the terms of the
resolution.

We recommend that only those students in the
last two years of training be eligible for member-
ship. We point out that this would permit those
in the first and second years to participate in the
Student American Medical Association chapter
which has recently been reactivated at the Uni-
versity of Mississippi School of Medicine.

We, therefore, request the Board of Trustees to
provide for provisional organization and provi-
sional charter of the University Medical Society
and for election to membership of those students
who apply.

Dr. J. T. Davis of Corinth moved to amend
the last sentence of the reference committee's re-
port to insert the words “a degree of member-
ship" immediately before the words “and for elec-
tion to" and the motion was seconded by Dr.
S. Jay McDuffie of Nettleton. The motion to
amend was adopted, and the main motion was
adopted as amended.

RESOLUTION NO. 9

Resolution No. 9 was withdrawn from consid-
eration by the House of Delegates.

RESOLUTION NO. 10, ASSOCIATION
FINANCIAL MANAGEMENT

Dr. J. T. Davis: Whereas, Matters relating to
association finances and the budget have, for
many years, been responsibilities of the Council
on Budget and Finance, a three-member body,
and

Whereas, The association, as has been true
of virtually all state medical associations, has in-
creased its programs of service, extended its ac-
tivities, and experienced growth in financial op-
erations, and

Whereas, It is desirable for the association to
have the benefit of a broader base of financial
management and monitoring than can now be

provided with a three-member body, now, there-
fore, be it

Resolved, That Section 7, Chapter IX, By-
Laws of the association, be amended to provide
for a five-member Council on Budget and Fi-
nance with terms so arranged that not more than
two members are elected annually by the House
of Delegates, and be it further

Resolved, That this amendment become opera-
tive at the 103rd Annual Session in 1971 so as to
provide for orderly arrangement and succession
in terms of members of the expanded council.

REPORT OF THE COUNCIL ON
CONSTITUTION AND BY-LAWS

This resolution proposes an expansion of the
membership of the Council on Budget and Fi-
nance to five members from the present three
members, and it involves making a minor change
in Section 7, Chapter IX of the By-Laws.

We approve this amendment and recommend
that it be adopted now to become operative at
the 103rd Annual Session in 1971 so as to provide
for orderly arrangement and succession in terms
of members of the expanded council.

The report of the council, acting as a reference
committee, was adopted.

RESOLUTION NO. 11, EMERGENCY
MEDICAL HELICOPTER PROJECT

Dr. Howard A. Nelson: Whereas, The State
of Mississippi, through Mississippi State Univer-
sity and other cooperating organizations, has con-
ducted a demonstration project on utilization of
helicopters for emergency medical transportation
with bases at Greenwood, Jackson, and Hatties-
burg, and

Whereas, The medical profession, through ex-
perience in the Korean War and the War in Viet
Nam, recognizes the helicopter as means of med-
ical air evacuation and emergency service trans-
portation without parallel in the saving of human
life in rapid movement of accident victims and
other emergency patients to centers of care, and

Whereas, The demonstration grant under
which the project is being conducted will soon
expire, and

Whereas, The project should be continued in
the interest of care of accident and emergency
patients and eventually established as a service
for Mississippians, now, therefore, be it

Resolved, That the Mississippi State Medical
Association applauds the emergency helicopter
service as vital to the public health and urges its
continuation by the State of Mississippi offering
support and endorsement of the service.

470

JOURNAL MSMA

REPORT OF THE REFERENCE COMMITTEE
ON MEDICAL PRACTICES

This resolution applauds the emergency heli-
copter demonstration project and recommends
continuation of service by the State of Mississippi.
We approve the resolution and recommend its
adoption.

The report of the reference committee was
adopted.

RESOLUTION NO. 12, INCENTIVE
TO PRACTICE IN RURAL AREAS

Dr. Guy T. Vise: Whereas, There is a short-
age of physicians in Mississippi where the ratio is
approximately half the physicians to population
that it is nationally, and

Whereas, The need for physicians is especial-
ly acute in rural areas where physician to popula-
tion ratio is even less than the low state average,
and

Whereas, Medical organization, in its contin-
uing effort to present positive programs for as-
sured care delivery to the American people, earn-
estly seeks solutions to these perplexing prob-
lems, now, therefore, be it

Resolved, That the Mississippi State Medical
Association recommends that appropriate tax in-
centives be provided to physicians who elect to
practice in rural areas of Mississippi and of other
states and further recommends that the Internal
Revenue Code of 1954 be accordingly amended
to provide this incentive.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

This resolution recognizes the shortage of phy-
sicians in Mississippi and seeks certain amend-
ments to the Internal Revenue Code of 1954 to
provide tax incentives for physicians to practice
in rural areas of the United States. We approve
the resolution and recommend its adoption.

The report of the reference committee was
adopted.

RESOLUTION NO. 13, SUPPLY
OF PHYSICIANS

Dr. Paul B. Brumby: Whereas, The Missis-
sippi State Medical Association recognizes that
there is a shortage of physicians in our state, and

Whereas, The association earnestly seeks so-
lutions to this urgent problem in the interest of
delivering medical care to all Mississippians, and

Whereas. The University of Mississippi
School of Medicine is the state’s primary source
of physicians, now, therefore, be it

Resolved, That the Mississippi State Medical
Association calls on the State of Mississippi to do
those things necessary in support of the Universi-

ty of Mississippi School of Medicine to increase
the size of classes of medical students to the end
that the state may enjoy the benefits of larger
graduating classes, and be it further

Resolved, That the association does endorse
such action and does offer its support in partner-
ship with the state in achieving this worthy end.

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

This resolution calls on the State of Mississippi
to do those things necessary in support of the Uni-
versity of Mississippi School of Medicine to in-
crease the size of classes of med:cal students to
the end that the State may enjoy the benefits of
larger graduating classes.

Your reference committee concurs with the
proponent of the resolution in that the University
of Mississippi School of Medicine is our primary
source of physicians. We, therefore, offer our en-
dorsement and support of any such programs
which will assist the University in enlarging classes
and the supply of physicians in our State and call
on all physicians to give of their best efforts in
this connection.

Dr. Ralph L. Brock of McComb moved to
amend the report of the reference committee by
deleting the period in the last sentence and add-
ing the words ‘'and be referred to the Council on
Legislation for implementation." Dr. H. C. Ricks,
Sr., seconded the motion to amend which was
adopted. The main motion was adopted as
amended.

RESOLUTION NO. 14, LOCATION
OF TRAINING FACILITY

Dr. James Grant Thompson: Whereas, The
Board of Trustees of the Mental Institutions of
the State of Mississippi has seriously and careful-
ly considered the location of a training institution
for the training of mentally retarded individuals
and

Whereas, Representatives from three locali-
ties adequately presented to this Board their rea-
sons why this facility should be located in their
areas, and

Whereas, The Board of Trustees of the Men-
tal Institutions of the State of Mississippi has de-
cided that due to certain existing conditions the
facility should be located at, in, or near Oxford,
Mississippi, now, therefore, be it

Resolved, The Mississippi State Medical Asso-
ciation does urge the approval of the location of
the training institution for the training of mental-
ly retarded individuals to be in or near Oxford,
Mississippi.

AUGUST 1970

471

HOUSE OF DELEGATES / Continued

REPORT OF THE REFERENCE COMMITTEE
ON MISCELLANEOUS BUSINESS

This resolution, emanating from the Board of
Trustees of Mental Institutions of the State of
Mississippi, refers to location of a training facility
which is being considered and planned for North
Mississippi for the mentally retarded. The resolu-
tion recommends that the institution be located in
or near Oxford, Mississippi.

We had informed discussion in this connection,
and we concur with those who support the loca-
tion of the institution in or near Oxford and rec-
ommend adoption of the resolution.

Dr. William E. Lotterhos, speaking as a mem-
ber of the House, moved to amend the report of
the reference committee by deleting from the last
sentence the words “concur with” and substitut-
ing therefor the words “have confidence in the
judgment of” and the motion was seconded by
Dr. J. T. Davis. The motion to amend was adopt-
ed, and the main motion was adopted as amend-
ed.

RESOLUTION NO. 15, CONDUCT
OF THE HOUSE OF DELEGATES

Dr. Howard A. Nelson : Whereas, Section 4,
Chapter V, By-Laws of the Association provides
that meetings of the House of Delegates shall be
conducted according to Robert’s Rules of Order,
Newly Revised, and

Whereas, The House of Delegates of the
American Medical Association has adopted the
Sturgis Standard Code of Parliamentary Proce-
dure, and

Whereas, It is desirable for the House of Del-
egates of this Association to seek a parallel par-
liamentary guide now, therefore be it

Resolved, That Section 4, Chapter V of the By-
Laws be amended to delete Robert’s Rules of
Order, Newly Revised and substitute therefor
Sturgis Standard Code of Parliamentary Proce-
dure.

Resolution No. 15, having been introduced on
the final day of the annual session and seeking an
amendment to the By-Laws, was received and
placed on the table for one year under the rules
of the House of Delegates.

OFFICIAL ATTENDANCE

The official attendance was announced as be-
ing 917 to include 473 physicians, 210 members
of the Woman’s Auxiliary, 114 exhibitors, 106
guests and others, and 14 staff.

REPORT OF THE REFERENCE COMMITTEE
ON RULES AND ORDER OF BUSINESS |

Conduct of Business. Your reference commit-
tee commends the Speaker and Vice Speaker for
the outstanding manner in which they have con-
ducted business before this House of Delegates.
We believe that all members will wish to associ-
ate themselves in this connection and in an ex-
pression of appreciation to these officers. We ap-
prove the remarks of the Speaker.

Resolution. Your reference committee desires
to offer the following resolution for consideration
by the House of Delegates:

Whereas, The 102nd Annual Session of the
Mississippi State Medical Association has been
conducted in Biloxi, Mississippi, during the peri-
od May 11-14, 1970, and

Whereas, The annual session has been most
profitable and enjoyable for for all who have been
in attendance, now, therefore, be it

Resolved, That expressions of deep apprecia-
tion are made to the officers, Trustees, and Coun-
cil on Scientific Assembly for the stimulating and
worthwhile scientific program; to the management
of the Buena Vista and other participating hotels;
to the press, radio, and television for coverage of
our activities; to the gracious ladies of the Aux-
iliary who always contribute so substantially to
our meetings; to the technical exhibitors and their
professional service representatives; to our scien-
tific exhibitors; to our distinguished guests; and to
all who shared in the responsibilities of planning,
organizing, and conducting this great annual ses-
sion.

Your reference committee recommends adop-
tion of this resolution.

The report of the reference committee was
adopted.

REPORT OF THE ELECTION OF OFFICERS

President-elect: Arthur E. Brown, Columbus.

Vice Presidents: John R. Lovelace, Batesville;
J. Dan Mitchell, Jackson; Eldon L. Bolton, Bi-
loxi.

Secretary-Treasurer: Raymond S. Martin, Jr.,
Jackson ( 1973) .

Speaker: William E. Lotterhos, Jackson (1973).
Vice Speaker: John B. Howell, Jr., Canton
(1973).

Associate Editor: George H. Martin, Vicksburg
(1972).

Delegate to AMA: C. D. Taylor, Jr., Pass Chris-
tian ( 197 1-72) .

Alternate Delegate to AMA: Stanley A. Hill,
Corinth (1971-72).

472

JOURNAL MSM A

Board of Trustees: Lyne S. Gamble, Greenville,
District 1; James O. Gilmore, Oxford, District
2; J. T. Davis, Corinth, District 3 (1973).

Council on Budget and Finance: Daniel L. Hol-
lis, Biloxi (1973).

Council on Constitution and By-Laws: Arthur E.
Brown, Columbus (1973).

Judicial Council: William E. Weems, Laurel, Dis-
trict 7; Wendall B. Holmes, McComb, District
8; James T. Thompson, Moss Point, District 9
(1973).

Council on Legislation: Arthur A. Derrick, Jr.,
Durant, District 4; John G. Caden, Jr., Jack-
son, District 5; Frank H. Tucker, Jr., Meridian,
District 6 (1973).

Council on Medical Education: Charles N. Floyd,
Gulfport ( 1973) .

Council on Medical Service: Charles R. Jenkins,
Laurel, District 7; Jack A. Atkinson, Brook-
haven, District 8; Bedford F. Floyd, Jr., Gulf-
port, District 9 (1973).

CONSTITUTION AND BY-LAWS

At the close of business, an amendment to Sec-
tion 4, Chapter V, of the By-Laws, as proposed
in Resolution No. 15, was lying on the table,
pending action at the 103rd Annual Session.

CLOSING CEREMONIES

There being no further business, the Speaker
returned the gavel to President Royals. The Oath
of Office was administered to Dr. Paul B. Brum-
by, the President-elect, by Dr. Mai S. Riddell, Jr.,
Chairman of the Board of Trustees, after which
Dr. Brumby addressed the House of Delegates.

Dr. James Grant Thompson of Jackson pre-
sented the Thompson Memorial Past President’s
Pin to Dr. Royals.

The House of Delegates was adjourned sine
die at 4:28 o’clock in the afternoon. May 14,
1970.

PRN

An invitation to dinner was sent to the town’s new doctor. In
reply, the hostess received an absolutely illegible letter. “I’ll have
to know if he accepts or not,” she said.

“Why don’t you take it to the druggist?” her husband suggested.
“They can always read doctors’ notes no matter how badly they’re
written.”

His wife went to the drug store and handed her druggist the
slip of paper. He looked at it, went into the dispensary and re-
turned a few minutes later with a bottle of pills. "Here you are,
Ma’am,” he said. "That’ll be $2.75.”

AUGUST 1970

473

This “case history” runs to some 10,000 pages

This is a typical "case history" of one new drug -or,
rather, a proposed new drug - assembled for submis-
sion to the U.S. Federal Food and Drug Administration,
These volumes are the result of several years’ work by
thousands of professional and skilled personnel in
just one pharmaceutical company's research labora-
tories, and by hundreds of physicians in medical
schools, hospitals, and private practice. They cover
every aspect of experience with this proposed new
agent from chemical laboratory to clinic, from mouse
to man. Each volume could conceivably represent
hundreds of thousands of dollars of financial invest-

ment, countless hours of human effort. This veritable
mountain of data stands behind every new agent
offered to you by pharmaceutical manufacturers — a
reassuring testimonial to the efficacy, safety and
purity of the drugs you will prescribe today to lower
the cost of disease to your patients.

Pharmaceutical
Manufacturers Association

Pharmaceutical
Advertising Council

1155 Fifteenth St., N W„ Washington, D C. 20005

This message is brought to you as a
courtesy of this publication on behalf of the
producers of prescription drugs.

Burdick

Taste!

ANTACID

Your ulcer patients and
others will love it. Specify
DICARBOSIL 144's — 144 tab-
lets in 1 2 rolls.

ARCH LABORATORIES

319 South Fourth Street. St. Louis, Missouri 63102

DIRECTED, DEEP-
TISSUE HEATING
WITH THE MW-200
MICROWAVE UNIT

The MW-200’s simplicity
of operation and ease
of electrode application
have contributed much
to the popularity of mi-
crowave diathermy. Mi-
crowave radiations can be reflected, focused
and directed. Treatment intensities may be
preset.

Write us for descriptive literature and com-
plete price information.

KAY SURGICAL INC.

663 North State St. * Jackson, Miss.

Index to Advertisers

Arch Laboratories 475

Breon Laboratories 0

Bristol Labs 16, 17

Burroughs-Wellcome 436D

Campbell Soup Company 436A

Carlton Corporation 12

Dow Chemical 440A

Eaton Laboratories 11

Flint Laboratories 7

Health Screening Centers, Inc. 15

Hill Crest Hospital 10

Hynson, Westcott and Dunning, Inc 3

Kay Surgical, Inc 475

Lederle Laboratories 4, 6

Leonard Wright Sanatorium 14

Eli Lilly and Company Front cover, 18

MPAC, AMPAC 426

National Drug Company . 444A, 444B, 464A, 464B

Pharmaceutical Manufacturers Association 474

William P. Poythress and Co., Inc 440B

Roche Laboratories Fourth cover

Schering Corporation 14A, 14B

G. D. Searle Co 436B. 436C

Smith, Kline and French second cover

Thomas Yates and Company third cover

AUGUST 1970

475

The half life of medical knowledge is only eight years, and this i
emphasized in a recent paper by Dr. Robin W. Bell-Irving of Van-
couver. Writing on "physician obsolescence , ’* he says that six
reasons get us ou t- o f-date: Ourselves and "unlearning; " misunder-,

standing about practice patterns; town-gown controversy; the monej
government axis; hospitals; and relationship to the health care te:
Bell-Irving formula is postgraduate study and ’’personalized'* practj

A six-county family planning program has been funded in central Mi.
sissippi by 0E0. Thrust of project is medical guidance for female
participants in Attala, Carroll, Choctaw, Holmes, Montgomery, and
Webster counties. Features of program include physicians* service,
counseling, supplies, and where necessary, transportation to clinij
Project is aimed at serving low income families. Initial grant is
$33,000 on application of f 153, 000 for entire program.

i ■■■■"■■ f

Family practitioners are earning more since the advent of Medicare
and Medicaid in 1965", but they are also working longer hours. Thi
is the finding of the American Academy of General Practice in a
study involving 1,000 general practitioners. Only those physician
working 66 to 70 hours a week managed to improve income by 26 per
cent, while 41-to-45 hour per week M.D. *s enjoyed less than 6 per
cent gain. Study counters accusation of zooming incomes.

Special telephone equipment for the handicapped can be an importar
rehabilitation aid. In a demonstration project involving 300 dis-
abled patients, N.Y. Medical Center and American Tel and Tel fumjl]
ed special phones, each tailored to individual patient need, to tl
seriously impaired patients. Follow up investigation showed how
easy-to-use phones improved morale and even helped patients to en-
gage in useful, productive activities.

Mutagenic properties of LSD have apparently been demonstrated by
vestigators at George Washington University. Sample was 127 preg-
nancies in 112 women who ingested 100 micrograms of drug before 03
during pregnancy. Of these, there were 65 abortions and 62 term
births. Fifty- three abortions were therapeutic with some related ;o
LSD. Among the 62 infants, 56 were normal except for one prematun
who died, and six had congenital defects attributed to LSD use.

Volume XI
Number 9

September 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.

Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary-Treasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. C. Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

ORIGINAL papers

Acute Alcoholic
Hepatitis — A Review

of 32 Cases 477 William M. McKell,
Jr., M.D., and Lidio
O. Mora, M.D.

Twenty-Seven Months of
Chemoprophylaxis for

Prevention of Tuberculosis

in Mississippi 485 Lee R. Reid, M.D.

Acute Bacterial Infections

in the Newborn 493 Dennis I. Wright, M.D.,

and Alfred W. Brann,
Jr., M.D.

SPECIAL ARTICLES

Radiologic Seminar XCIX:

Endometriosis: An
Unusual Cause of

Colon Obstruction 502 Walter T. Colbert,

M.D.

Fifty-One Years in the
Art: A Family

Physician Remembers 504 Profile of Service

EDITORIALS

The College and Cancer:

Saga of Enlightened

Leadership 507 Reasons for Registries

Rx for Inflation and

Drug Costs 509 Bargains in Health

Why Not More Dental

Care Insurance? 510 Just 3 out of 100

Ingratitude and Calumny

and Sen. Hughes 51 1 Take AMA on!

Button Power, Teenage

Style 512 Don’t Meth Around

THIS MONTH

The President Speaking 506 ‘Dilemma in Blue’
Medical Organization 519 New Membership Service

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR SEPTEMBER 1970

with the field of host resistance as an approach
to the control of virus infections.

Still another section describes enzymes, and
particularly the ribonuclease enzyme, “as a model
from which we may learn how to design medi-
cines to combat disease at the molecular level.”

In briefly relating the steps by which a new
product proceeds from discovery to marketing, the j
booklet underlines the importance of industry-
government cooperation in producing safe and ef-
fective medicines.

“There were 851 major new medicines de-
veloped from 1940 through 1969 and nearly two-
thirds of these originated in the United States,”'
the booklet says. “In the last three years, as an
example, 50 totally new drugs and vaccines were
added to the armament of the physician . . . and
48 of them emerged from pharmaceutical industry
research.”

The 16-page booklet has several full-color il-
lustrations of the cell, the central and peripheral
nervous system, normal and hypertensive blood
vessels, and a laboratory model of the ribo-
nuclease enzyme. A bibliography lists 22 books
on the health sciences.

Single copies are available on request from the
Public Relations Division, Pharmaceutical Manu-
facturers Association, 1155 Fifteenth Street,
N. W., Washington, D. C. 20005.

LEONARD WRIGHT SANATORIUM

BYHAUA, MISSISSIPPI 3861 1 TELEPHONE A/C 601, 838-2162

LEONARD D. WRIGHT, SR., B.S., M.D., PSYCHIATRY

• Established in 1948. Specializing in the treatment of ALCO-
HOLISM and DRUG ADDICTIONS with a capacity limited
to insure individual treatment. Only voluntary admissions ac-
cepted.

• Located 25 miles S. E. of Memphis-Highway 78 on 20 acres
of beautifully landscaped grounds sufficiently removed to
provide restful surroundings.

• The Sanatorium is approved by The Commission on Hospital
Care in the State of Mississippi.

PMA Produces
New Booklet

The quest of pharmaceutical industry scientists
for the medicines of tomorrow is described in a
new illustrated booklet published by the Phar-
maceutical Manufacturers Association.

Entitled Molecules, Medicines and You,
the booklet depicts in lay language the unending
search for new and improved products along such
frontier areas as molecular biology and tells what
scientists know — and do not know — about the
ways medicines work within the body.

The booklet first describes the cell and the ap-
proach scientists are taking to find out how speci-
fic drugs link to cell molecules, one reason being
to eliminate or minimize side effects. Another
section relates how today’s researchers study
molecular disturbances in the nervous system and
seek specific medicines to restore its intricate bal-
ance and the patient’s mental health.

A third section deals with malfunctions of the
heart or blood vessels, noting that scientists are
delving into the “exciting field of microvessels . . .
on the frontier where coronary heart disease be-
gins.” Viruses are another subject, with the
gains through immunization mentioned, along

1

i Doctor:

September 1970

i cal care foundations under the control of physicians are shaping
s the health care delivery system of the 1970 fs. Developed in
fomia, the foundation concept is moving east with, recently-
iated organizations in Colorado and New Mexico. Iowa is also
ing up statewide foundation, and Florida and Georgia are now in
1 planning stages.

Foundations are medical association-sponsored, nonprofit
entities standing between the provider and third parties.
Seart of system is peer review and physician control of
professional fee payment. California foundations admin is
ter both Medicare and Medi-Cal (Medicaid).

amates are out under new Food and Drug Administration order which
all use of artificial sweeteners in class7 New edict comes after
1 ruling on cyclamate-sweetened soft drinks and extends to fruits
vegetables. Food processors say that losses of inventories to be
royed will run into the millions. Under FDA order, there is no
ision for a hearing or appeal to stay the action.

isrsity Medical Center has announced a new training program for
ial hygienists. Course will be 2l months in duration, and first
s will consist of 20 trainees. Program is under UMC*s Office of
ed Health Professions, and director is Dr. James R. Hatten, in-
ctor in surgery (dentistry). Funds for project were provided by
regular session of legislature, and project is supported by the
issippi Dental Association.

al Security Administration warns that misleading advertisements
being sent to Medicare beneficiaries "in the Mississippi area,
in gs promote supplemental insurance for sale by mail and tend to
impression that company is connected with SSA. One mailer uses
ndow envelope which closely resembles those used by government
ail benefit checks. Most carriers selling supplemental insurance
reputable and describe policies honestly.

bill introduced In U. S. Senate would provide $4*5 million for
ly practice scholysbips and residencies. Sponsored by five
blican senators, S. 425b would offer 500 medical scholarships
200 residencies in first year. Awardees would agree to practice
reas with physician shortages or serve migratory farm workers.

THE JOURNAL FOR SEPTEMBER 1970

1 0

U.S.P./N.F. Merger
Talks Begin

U.S.P./N.F. unification was discussed by offi-
cials of the United States Pharmacopeial Con-
vention, Inc. and the American Pharmaceutical
Association at A.Ph.A. headquarters in late sum-
mer.

Following the meeting, it was announced that
an agreement had been reached to develop a
master plan for a cooperative venture between
the U.S.P. and N.F. Following development by
the staffs of U.S.P. and N.F., the plan is to be con-
sidered by the A.Ph.A. Board of Trustees and the
U.S.P.C. Board of Trustees.

Representing U.S.P. at the meeting were Dr.
John H. Moyer, President; Dr. Paul L. McLain,
Chairman of the Board of Trustees; Dr. William
M. Heller, Executive Director; Dr. Thomas J.
Macek, Director of Revision; and Joseph G.
Valentino, J.D., Executive Associate. Represent-
ing A.Ph.A. at the meeting were Dr. William S.
Apple, Executive Director; Grover C. Bowles,
D.Sc., Treasurer and member of the Executive
Committee; Dr. Edward G. Feldmann, Associate
Executive Director for Scientific Affairs; and Dr.
John V. Bergen, Director of the National For-
mulary.

A resolution was adopted at the April meeting
of the U. S. Pharmacopeial Convention urging in-
tensified efforts “to coordinate the activities and
programs of the United States Pharmacopeia and
the National Formulary, and to explore the ad-
vantages and feasibility of unification of these ac-
tivities and programs with the objective of pro- )
ducing a single compendium of standards and tests \
for official drugs and dosage forms.”

Wyeth Adds
to Tubex Line

Wyeth Laboratories has added diphenhydra-
mine hydrochloride, 50 mg. per ml., to its Tubex
line of unit dose medications in prefilled sterile
cartridge-needle units.

Diphenhydramine is supplied in packages of
ten-1 ml. Tubex units.

With the addition of diphenhydramine hydro-
chloride, Wyeth's Tubex line of injectables now i
includes 37 drugs and 68 dosage variations — con- t.
tinuing to make it the broadest line of prefilled
injectables available.

Also, Wyeth's unit dose medications include
an extensive selection of oral solids, liquids and
suppositories in Redipak® single-unit packages for
hospitals.

yjkff G/tegf

HOSPITAL

Hill Crest Foundation, Inc.

7 000 5TH AVENUE SOUTH
Box 2896,

Birmingham, Alabama 35212

Phone: 205-836-7201

A patient centered
non-profit hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 45 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James K. Ward, M.D., F.A.P.A.

CLINICAL DIRECTOR:

Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

G/iest

HOSPITAL

BIRMINGHAM, ALABAMA

.

!

I

: day Weekend New York - The Norwegian Medical Association has
• sures Workers released a study report of the two-day weekend

which, it seriously concludes, is too short.

: ings say that pressures on Norwegians to get out of town Friday
;moon, fight traffic, live it up until Sunday, and return ex-
; ted leaves them unfit to begin normal workweek on Monday. Re-
: suggests 32-hour week with three days off but doesn't say how
: of the same with extra day would help dilemma.

Gets Clean Washington - The tempest in a shaker over pos-

i, of Health sible dangers of monosodium glutamate, popular

and widely used flavor enhancer in foods, is
i‘. National Academy of Sciences and National Research Council
j'! MSG clean bill of health after safety was questioned along with
.amates. FDA still got in last word with statement that since
*e is no nutritional value in MSG, it should not be in ingredients
»aby foods.

>oration Guides Chicago - Generalized criteria for profitability
Outlined of organizing a professional corporation by M.D. *s

have been drawn by practice management consultants,
t rule of thumb, there should be at least two physicians or more in
aaership with individual earnings of $35,000 per year before taxes.
;ributions to retirement should be about $7,000 annually over 20
’s per professional shareholder. Marginal practice situations,
guides, should be surveyed before incorporating.

I Accredits 46 Jackson - Forty-six of Mississippi's 128 hospitals
be Hospitals are fully accredited by the Joint Commission on

Accreditation of Hospitals, according to new list
b released. For first time, there are no provisional or temporary
bifications, and most encouraging sign is that many smaller hos-
ils have now qualified. JCAH also reports no accredited extended
3 facilities in state and only one fully accredited nursing home.

pital Costs Chicago - The American Hospital Association says

v Major Rise hospital expenses increased 17.3 per cent in 1969

over 1968 and upsurge shows no sign of abating,
patient day costs rose to national average of $70 from $61 year
Dre. Personnel continues to be major cost factor with almost $10
Lion payroll in nation's 6,000 community hospitals. Typical ratio
280 hospital employees per 100 patients, up from 272 in 1968. To-
institutional employment is now 2.4 million in 7,150 public and
vate hospitals.

Levothyroxine has a high binding capacity for
serum proteins in contrast to other thyroid
medicaments that may contain a thyroactive
agent with low binding capacity. The bound
levothyroxine is totally measurable using the serum
PBI test. It is not unusual to find PBI levels of
8-10 meg. per 100 ml. of serum. \
INDICATIONS: SYNTHROID (sodium levothyroxine)
INJECTION is specific replacement therapy
for diminished or absent thyroid function
resulting from primary or secondary atrophy of
the gland, congenital defect, surgery, excessive
radiation, or antithyroid drugs. It is indicated in
myxedematous coma and other thyroid
dysfunctions where rapid replacement of the
hormone is required. When a patient does not
respond to oral therapy, SYNTHROID (sodium
levothyroxine) INJECTION may be administered
intravenously.

PRECAUTIONS: As with other thyroid
preparations, overdose may cause diarrhea or
cramps, nervousness, tremors, tachycardia,
insomnia and continued weight loss. These effects
may become apparent in from 4 days to three
weeks. Therefore, patients should be kept under
close observation. Medication, in such cases,
should be stopped for 2 to 6 days, then resumed
at a lower level. In patients with diabetes „

mellitus, look for possible changes in metabolic
activity which may affect insulin or other
antidiabetic drug dosage requirements.
CONTRAINDICATIONS: Thyrotoxicosis, acute
myocardial infarction.

SIDE EFFECTS: Side effects are secondary to
increased rates of body metabolism: sweating,
heart palpitations with or without pain, leg
cramps, weight loss, diarrhea, vomiting and
nervousness. Myxedematous patients with heart
disease have died from abrupt increases in
dosage of thyroid drugs. In most cases, a
reduction in dosage followed by a more gradual
adjustment upward will indicate the patient's
dosage requirements without the appearance of
side effects.

DOSAGE AND ADMI

myxedematous stupor o
of severe heart disease,

SYNTHROID (sodium levothyroxine) INJl
may be administered intravenously utilizii
solution containing 100 meg. per ml. Dete
effects are usually observed by the sixth
after injection and are fully appreciated
the following day. A repeat injection of 1
200 meg. may be given on the second dc
significant improvement has not occurred,
intravenous use of sodium levothyroxine ir
myxedematous coma is advantageous bei
produces a predictable increase in the
concentration of protein-bound iodine,
eliminates the need for multiple doses unti
therapy is reinstated, circumvents the unc
of oral absorption, and avoids the risk o
pulmonary aspiration.

SUPPLIED: SYNTHROID (sodium levothyr
INJECTION is supplied in 10 ml. vials con
500 meg. of lyophilized active ingredien
10 mg. of Mannitol, N.F.; a 5 ml. vial co
Sodium Chloride Injection, U.S.P. is provi
as diluent.

Also supplied as SYNTHROID (sodium
levothyroxine) TABLET in color coded co
tablets, and in seven strengths: 0.025 mgj
(orange), 0.05 mg. (white), 0.1 mg. (yell
0.15 mg. (violet), 0.2 mg. (pink), 0.3 mg
(green), and 0.5 mg. (blue). Each strengt
supplied in bottles of 100 and 500 tabl

Synthroid

(sodium levothyroxine, F

Injection

FLINT LABORATORI

DIVISION OF TRAVENOL LABORATORIES. INC.
Morton Grove, Illinois 60053

In tablet form this single entity
synthetic thyroid provides
smooth, predictable response
for thyroid replacement. An
excellent drug for long-term
therapy.

But in an emergency, when
rapid replacement is needed to
sustain life, prompt clinical
response is essential. SYNTHROID
injection makes this therapy
instantly available. Is it available
in your hospital?

When an ambulance arrives
with the unexpected patient
presenting the classical picture
of myxedema coma, is your
hospital suitably equipped? It
is if SYNTHROID® (sodium
levothyroxine) injectable is at
hand. You are also ready°to
conveniently handle post-
operative thyroid medication
situations until oral therapy can
be reinstated.

Military Surgeons Hold
77th Annual Meeting

Emphasizing the theme “Controversies in Med-
icine,” medical officers of the three military ser-
vices will convene with physicians of the Public
Health Service and the Veterans Administration
for the 77th Annual Meeting of the Association of
Military Surgeons of the United States, to be
held at the Washington Hilton Hotel Nov. 29-
Dec. 2, V.Adm. George M. Davis, MC, USN,
the Surgeon General of the Navy and President
of the Association, has announced.

Medicine’s top man in the Nixon Administra-
tion, Dr. Roger O. Egeberg, the Assistant Secre-
tary for Health, Education and Welfare, will
deliver the keynote address on Monday morning,
Nov. 30.

As currently planned, the scientific program,
under the direction of R.Adm. George H. Reifen-
stein, MC, USNR, will begin with a discussion
on “Controversies of Management: Inflammatory
Bowel Disease,” with W. M. Lukash, MC, USN
as Chairman, assisted by Lt.C. W. Boyce, MC.
USA as Co-Chairman.

Other topics of clinical medical interest will in-
clude panel discussions centering on “Controver-
sies in Management of Neurosurgical Problems,
Intercranial Foreign Bodies . . . ,” moderated
by Dr. C. Hunter Shelden, and “The Federal
Physician’s Attitude Toward Alcoholism.” moder-
ated by Capt. C. L. Waite, MC, USN. Capt.
Waite’s panel will also discuss “Computers and
Medicine, a Perspective.” These panels will be
conducted on Dec. 1 and 2, respectively.

Following the Awards Program on Tuesday,
an additional panel will take as its topic, “Prob-
lems Involved in Integrating Teaching and Re-
search.” The program will be chaired by Capt.
J. William Cox, MC, USN.

Col. Nelson Irey, MC, USA Ret. will deliver
the Sustaining Membership Lecture entitled, “Con-
troversies of Diagnosis: Alleged Drug Reactions.”
R.Adm. F. P. Ballenger, MC, USN, General
Chairman of the convention, will act as moder-
ator.

The William C. Porter Lecture in Psychiatry
will be given this year by Capt. Ransom Arthur,
MC, USN. His paper is entitled, “Success Is Pre-
dictable.” The Porter Lecture was established in
1958 by the Association, which has been called
the Medical Society of the Federal Agencies, to
honor William C. Porter, a pioneer in military
psychiatry.

calcium glycerophosphate, calcium lactate

To bring effective calcium therapy to the
patient, Calphosan may be administered intra-
muscularly . . . without pain, inflammatory reactions,
induration or sloughing. Injections twice weekly
for a series of 5 to 10 injections are recommended.

Average dose per injection: One or two 10 ml.
injections of Calphosan each week for the
first four or five weeks, and on a when-needed
basis thereafter.

Calphosan is a specially processed solution of
calcium glycerophosphate and calcium lactate,
containing 1% of each, in a physiological solution of
sodium chloride. Each 10 ml. contains 50 mg. of
calcium glycerophosphate, 50 mg. calcium lactate,
with 0.25% phenol as preservative. Available in
10 ml. ampules in boxes of 10s and 100s;

60 ml. multiple-dose vials. Also available as
Calphosan with B-12. U. S. Patent No. 2657172.

Contraindication: Hypercalcemia; neoplastic
diseases; and fully digitalized patients. Do not use
intramuscularly in infants and young children.
Before starting therapy, consult complete
product literature.

Write for free copy of ‘‘Calcium: The Ubiquitous
and Essential Element” and for samples.

CARLTON

Tenafly, New Jersey 07670

Aerosol Sputum
Unit Developed

A machine to help eliminate the hazard of
contamination in the respiratory disease diag-
nostic areas of hospitals and clinics during the
collection of aerosol induced sputum samples, has
been developed by a Brigham Young Univer-
sity professor.

Dr. Marcus M. Jensen, who specializes in the
environmental control of airborne microorganisms,
has designed a mobile aerosol-sputum induction
unit to be used in conjunction with the laboratory
diagnosis of tuberculosis and other respiratory
diseases.

Four prototype machines have been in use in
Los Angeles hospitals during the past year. These
have been successful enough to prompt further
orders which are presently being executed by a
Provo firm.

The top half of Dr. Jensen's unit has a fold-
down shelf and two doors which open out to form
a cubicle which is called the “hood.” The patient
is seated facing the hood which is made from
stainless steel.

The output tube from a standard commercial
nebulizer attaches to a nozzle on the outside of
the hood, and a disposable tube carries the aerosol
mist from the nozzle to the patient’s mouth. The
inhalation of the mist by the patient induces
coughing which in turn carries microorganisms or
cancer cells from the lungs in the sputum. The
sputum samples are collected and analyzed by
the laboratory. All airborne droplets generated by
the induced coughing are drawn by a strong air-
stream into the unit and trapped by an absolute
filter.

The stainless steel hood can be easily decon-
taminated between patients by swabbing with an
effective germicide. A storage compartment is pro-
vided for the nebulizer and for items such as spu-
tum containers and disposable tubes. The com-
plete unit can be readily moved from patient to
patient if necessary.

Dr. Jensen developed the mobile aerosol-
sputum induction unit in association with Dr.
Seymour Froman of the Olive View Hospital,
in Olive View, Calif. Several years ago, Dr. Fro-
man convinced Dr. Jensen that there was a need
to protect hospital personnel from contaminated
air in diagnostic areas. Then, as Jensen produced
the prototypes and refinements, Froman tested
them under actual clinical conditions and sug-
gested various improvements.

Brief Summary of Prescribing Information-

9-9/ 22/ 69. For complete information consult
Official Package Circular.

Indications: Essential hypertension. Use cau-
tiously in patients with renal insufficiency,
particularly if they are digitalized.
Contraindications: Anuria, oliguria, active
peptic ulceration, ulcerative colitis, severe de-
pression or hypersensitivity to its components
contraindicates the use of Salutensin.
Warnings: Small-bowel lesions (obstruction,
hemorrhage, perforation and death) have
occurred during therapy with enteric-coated
formulations containing potassium, with or
without thiazides. Such potassium formula-
tions should be used with Salutensin only
when indicated and should be discontinued
immediately if abdominal pain, distension,
nausea, vomiting or gastrointestinal bleeding
occurs. Use cautiously, and only when deemed
essential, in fertile, pregnant or lactating pa-
tients. Use in Pregnancy: Thiazides cross the
placenta and can cause fetal or neonatal
hyperbilirubinemia, thrombocytopenia,
altered carbohydrate metabolism and possibly
electrolyte disturbances. Fatal reactions may
occur with reserpine during electroshock
therapy; discontinue Salutensin 2 weeks be-
fore such therapy. Increased respiratory
secretions, nasal congestion, cyanosis and
anorexia may occur in infants born to reser-
pine-treated mothers.

Precautions: Azotemia, hypochloremia, hypo-
natremia, hypochloremic alkalosis and hypo-
kaliemia (especially with hepatic cirrhosis
and corticosteroid therapy) may occur, par-
ticularly with pre-existing vomiting and diar-
rhea. Potassium loss or protoveratrine A may
cause digitalis intoxication. Potassium loss
responds to potassium-rich foods, potassium
chloride or, if necessary, discontinuation of
therapy. Stop therapy if protoveratrine A
induces digitalis intoxication. Serum am-
monia elevation may precipitate coma in
precomatose hepatic cirrhotics. Discontinue
therapy 2 weeks before surgery or if myo-
cardial irritability, progressive azotemia or
severe depression occur. Exercise caution in
patients with chronie uremia, angina pec-
toris, coronary thrombosis or extensive cere-
bral vascular disease or bronchial asthma and
in those with a history of peptic ulceration or
bronchial asthma; in post-sympathectomy pa-
tients; in patients on quinidine; and in pa-
tients with gallstones, in whom biliary colic
may occur. Patients who have diabetes
mellitus or who are suspected of being pre-
diabetic should be kept under close observa-
tion if treated with this agent.

Adverse Reactions: Hydroflumethiazide: Skin
rashes (including exfoliative dermatitis), skin
photosensitivity, urticaria, necrotizing angiitis,
xanthopsia, granulocytopenia, aplastic
anemia, orthostatic hypotension (potentiated
with alcohol, barbiturates or narcotics), aller-
gic glomerulonephritis, acute pancreatitis,
liver involvement (intrahepatic cholestatic
jaundice), purpura plus or rninus throm-
bocytopenia, hyperuricemia, hyperglycemia,
glycosuria, malaise, weakness, dizziness, fa-
tigue, paresthesias, muscle cramps, skin rash,
epigastric distress, vomiting, diarrhea and
constipation. Reserpine: Depression, peptic
ulceration, diarrhea, Parkinsonism, nasal stuf-
finess, dryness of the mouth, weight gain,
impotence or decreased libido, conjunctival
injection, dull sensorium, deafness, glaucoma,
uveitis, optic atrophy, and, with overdosage,
agitation, insomnia and nightmares. Proto-
veratrine A: Nausea, vomiting, cardiac ar-
rhythmia, prostration, blurring vision, mental
confusion, excessive hypotension and brady-
cardia. (Treat bradycardia with atropine and
hypotension with vasopressors.)

Usual Dose: 1 tablet b.i.d.

Supplied: Bottles of 60, 600, and 1000 scored
50 mg. tablets.

Salutensin

hydroflumethiazide, 50 mg./reserpine,
0.125 mg. protoveratrine A, 0.2 mg.

BRISTOL LABORATORIES
Division of Bristol-Myers Company
Syracuse, New York 13201

BRISTOL

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

September 1970, Vol. XI, No. 9

Acute Alcoholic Hepatitis—
A Review of 32 Cases

WILLIAM M. McKELL, JR., M.D. and LIDIO O. MORA, M.D.

Jackson, Mississippi

The clinically recognizable effects of heavy
alcohol consumption on the liver range from com-
pletely reversible fatty infiltration to chronic ir-
reversible cirrhosis with its varied complications.
There is general agreement as to the existence of a
definite syndrome in alcoholics characterized
clinically by jaundice, leukocytosis, fever and
abdominal pain, and histologically by cellular
necrosis, parenchymal disorganization and a type
of hyaline degeneration. It has been suggested
that this entity is the link between the alcoholic
fatty liver and nutritional cirrhosis.1’ 2

Acute alcoholic hepatitis is the most widely
used label for this condition, however a multipli-
city of names exist: “florid cirrhosis,1'1 “ste-

atonecrosis-Mallory body type,”3 “progressive al-
coholic cirrhosis,”4 “acute hepatic insufficiency
of the chronic alcoholic”5 and “sclerosing hyaline
necrosis of the liver.”6 The variablity of terms
used to denote this syndrome indicate the differ-
ent criteria used in selection of cases. Therefore
the clinical picture and prognosis may differ mark-
edly, depending on which author one reads.

From the Department of Medicine, Division of Gastro-
enterology, University of Mississippi School of Medi-
cine.

Most studies have required the presence of
“alcoholic hyaline,” seen almost exclusively in
livers of alcoholics, for inclusion into this syn-

Acute alcoholic hepatitis comprises the
syndrome frequently seen in alcoholics
characterized clinically by jaundice, leuko-
cytosis, fever and abdominal pain, and his-
tologically by cellular necrosis, parenchymal
disorganization and a type of hyaline degen-
eration. The authors discuss 32 cases, de-
fining significant prognostic features and
management.

drome. Mallory7 in 1911 first described this his-
tologic abnormality consisting of a coarse acido-
philic meshwork of hyalinized cytoplasm, often
perinuclear, which is seen frequently in alcoholic
liver disease.

The present study was undertaken for the pur-
pose of reviewing experience in Mississippi with
this entity and in order to attempt to define any
significant prognostic features which would be val-

SEPTEMBER 1970

477

ALCOHOLIC HEPATITIS / McKell et al

uable to the clinician in his approach to the pa-
tient with acute alcoholic hepatitis.

Clinical Material: The material available for
analysis consisted of clinical records and liver
sections of 32 patients, from both the Veterans
Administration Hospital and the University of
Mississippi School of Medicine. In thirteen (40.6
per cent) of these, classified as Group A, both
clinical and histologic criteria for acute alcoholic
hepatitis (AAH) were met. In the great majority
of instances they presented with fever, abdominal
pain, and jaundice. Upon examination, they were
found to have abdominal tenderness and hepa-
tomegaly, with temperature elevations and leuko-
cytosis also present. Liver biopsies revealed focal
cellular necrosis, polymorphonuclear infiltration,
Mallory bodies and parenchymal disorganization.
These acute changes were superimposed on vari-
ous degrees of fatty metamorphosis and cirrho-
sis.

In fourteen patients (43.7 per cent), classi-
fied as Group B, the classical clinical features
were absent, only the histologic criteria were ob-
served. In Group C, consisting of five patients
(15.6 per cent), the clinical criteria alone were
met, without the classic acute histologic findings
being seen. The survival rate in the entire series
was 62 per cent, 54 per cent of those in Group
A surviving, 71 per cent of Group B and 60 per
cent of Group C.

JAUNDICE
ASCITES
ANOREXIA
WEIGHT LOSS
ABDOMINAL PAIN
FEVER

G. I. BLEEDING

91 %

Survivors

Non-survivors

Figure 1

Methods: All sections studied were stained with
hematoxylin and eosin. The specific findings noted
and graded were: fat, presence and type of cir-

rhosis, inflammation, Mallory bodies, cholestasis, ,
and necrosis. The degree of fatty infiltration and
number of Mallory bodies were each graded as
± to 4+. The presence of fat or Mallory bodies
in less than five per cent of cells was categorized as
±, in 5-25 per cent of the cells as 1 + , in 25-50
per cent of the cells as 2+, in 50-75 per cent of
the cells as 3 + , and in greater than 75 per cent
of the cells as 4-K Cirrhosis was classified as (a)
“diffuse, Laennec type,” or (b) “mixed cirrho-

HEPATOMEGALY

SPLENOMEGALY

ABDOMINAL

TENDERNESS

NEUROLOGICAL

ABNORMALITIES

ALTERED

SENSORIUM

Figure 2

sis.”8 Inflammation and cholestasis were each
recorded as mild, moderate or marked, and ne-
crosis and focal or diffuse.

Incidence: Ages of patients ranged from 27 to
68 with an average age of 48.15 years. The
average age of those who expired was 51.08 years,
of the survivors 46.40 years. A sex incidence in
this series would not be valid since the majority
(22 patients, or 68.7 per cent) of our patients
were from the Veterans Administration Hospital.
There were only three females included in our
study. There were 24 white and eight black pa-
tients included.

Clinical History and Physical Status: This
being a retrospective study, no reliable data on
the adequacy of nutritional habits, years of signifi-
cant alcohol intake, or interval between the last
drink and time of admission to the hospital was
available. It was usually inferred in the charts
that the years of heavy drinking had been “many”
or the patient was referred to as a “chronic alco-
holic.” The primary symptoms elicited from these
patients upon their admission to the hospital are
shown in Figure 1.

The most common presenting complaints in
those patients who ultimately survived were fever
(this was confirmed by documentation of an oral
temperature greater than 99 degrees on day one
or two of hospitalization in all cases) in 65 per
cent, and jaundice (this was noted to be clinically

478

JOURNAL MSM A

evident and chemically proven in all cases) in
50 per cent. Also elicited in the histories of sur-

Figure 3

viving patients were weight loss (45 per cent);
abdominal swelling (found clinically to be accum-
ulation of ascitic fluid) in 40 per cent; and in 35
per cent each, anorexia, abdominal pain and
gastrointestinal bleeding (either hematemesis or
melena). In those patients who died of this ill-
ness, or some complications thereof, during this
admission, 91 per cent complained of abdominal
swelling, 75 per cent of GI bleeding, 66 per cent
of jaundice and 65 per cent of fever. As can be
readily noted this latter group, from history alone,
were sicker on admission than those who survived.

The physical abnormalities noted to be present
on admission are shown in Figure 2. Despite the
variance in the clinical histories between the sur-
vivors and non-survivors, it is noted that the
physical findings were remarkably similar. It
should be pointed out however that two items listed
as historical findings were borne out on physical

examination and were significantly different be-
tween the two groups, these being ascites and evi-
dence of gastrointestinal bleeding. Other than
these and jaundice and fever (also listed as his-
torical findings), the more frequent physical ab-
normalities were hepatomegaly, neurological ab-
normalities, and an altered sensorium.

Laboratory Values: The incidence of abnormal
hematologic and biochemical values (including
various tests of liver function) is shown in Figure
3. These refer to, in the vast majority, tests per-
formed on admission or within 48 hours thereof.
The most commonly noted abnormalities were
anemia (found in 75 per cent of survivors and
100 per cent of non-survivors), hyperbilirubine-
mia of the direct-reacting fraction (seen in 75
per cent of survivors and 91 per cent of non-sur-
vivors) and abnormal retention of bromsulphal-
ein (occurring, of those tested, in 94 per cent of
survivors and 100 per cent of non-survivors) —
this of course is readily explainable by the fre-
quent accompanying hyperbilirubinemia. The ane-
mia was relatively mild, the hemoglobin being
between 10 and 13.8 gm in 53 per cent of cases.
The leukocytosis seen in 40 per cent of the sur-
vivors and 66 per cent of non-survivors was
usually mild (only seven patients or 22 per cent
had a total WBC greater than 15,000/mm3) and
was of a normal differential count. The SGOT
levels were elevated in only 40 per cent and 25
per cent of survivors and non-survivors respective-
ly and the alkaline phosphatase levels were ab-
normal in only 10 per cent of survivors and 50
per cent of non-survivors. This was somewhat
suprising, for the biochemical abnormality in
A.A.H. has been described as suggesting liver cell
damage with some intrahepatic obstruction.9

There was hypoalbuminemia noted in roughly
one-half of both groups, however hyperglobuline-
mia was noted in one third of the non-surviving
patients, but only in five per cent of survivors.
Prolonged prothrombin times were noted in ap-
proximately one-half cases in each group, hypoka-
lemia in one-third, and elevations of serum cho-
lesterol in one-fourth. There was a rather marked
difference in the frequency of hyponatremia and
of elevated BUN levels between the two groups,
the serum sodium being less than 140 mEq/L in
35 per cent of survivors, but in 83 per cent of
those who did not survive; azotemia was noted
in 10 per cent and 58 per cent of survivors and
non-survivors respectively.

Histologic Changes: The incidence of various
histologic abnormalities is shown in Figure 4.
Cirrhosis was seen in almost all cases, being ab-
sent in only 25 per cent of the cases who survived.
The incidence of Laennec’s and ‘‘mixed" cirrhosis

SEPTEMBER 1970

479

ALCOHOLIC HEPATITIS / McKell et al

was equal in the non-survivors (50 per cent
each), and the “mixed” type was seen twice as
frequently in the survivors as in the Laennec type
(50 per cent and 25 per cent respectively).

Fatty metamorphosis of some degree was seen
in all patients, ranging from slight (±) to 3 +
(occurring in 50-75 per cent of all cells). There
was no significant difference in the amount of
fat seen between the two groups. An inflammatory
cell response consisting of polymorphonuclear
leukocytes and round cells, as in the Laennec type
leukocytes and round cells was seen to some de-
gree in all sections. This was more marked in
those who expired than in survivors. Mallory bod-
ies were seen in all patients except one case who
died eight days after admission. Their prevalence
ranged from slight to 3+, with no significant dif-
ference between survivors and nonsurvivors.

TABLE 4

% INCIDENCE OF HISTOLOGIC FEATURES

Histologic Feature

Group
SURVIVORS NON-i

SURVIVORS

Cirrhosis

None

25

0

1 aen nee's (a)

25

50

Mixed ( b )

50

50

Fat

0

0

0

+

40

25

+

20

42

-H-

20

25

+++

20

8

++++

0

0

Inflammation

0

0

0

Mild

20

9

Moderate

55

25

Marked

25

66

Mallory Bodies

0

0

8

+

15

9

+

35

25

++

35

25

+++

15

25

-H-++

0

8

Cholestasis

0

25

8

Mild

50

17

Moderate

20

33

Marked

5

42

Necrosis

0

15

17

Focal

70

50

Diffuse

15

33

In one patient, a 46-year-old black female who
died eleven days after admission, Mallory bodies
were noted in 75-100 per cent of cells. Cho-
lestasis was present in seven per cent of the sur-
vivors and 92 per cent of the non-survivors, with
the bile casts noted in 75 per cent of the latter.
Necrosis, either diffuse or focal, was seen in
approximately 85 per cent of each group.

DISCUSSION

There is general agreement as to the existence
of a definite syndrome in the alcoholic, usually
acute and with rather significant morbidity and
mortality, which is characterized clinically by fever
and jaundice and histologically by a peculiar
form of hepatic intracellular hyaline. The overall
outlook for this entity ranges from quite good to
almost invariably fatal, depending to a great ex-
tent on one’s criteria for patient selection. Phillips
and Davidson5 divided their group of fifty-six
patients into two groups: one with “the lesion
complex” (hyaline degeneration, cellular necrosis
and parenchymal disorganization), and one group
without “the lesion complex.” Of the 28 patients
in Group 118 died, running an average course of
1 1.7 days, whereas of the 26 patients in Group II,
only five died.

Mallory bodies are usually thought indicative
of a poor outcome. A group of 40 patients with
fatty metamorphosis and/or portal cirrhosis, one-
half with and one-half without Mallory bodies
was studied.11 The “Mallory body group” was
found to have more hospitalizations, more hema-
temesis and ascites, less hepatosplenomegaly, less
neurological and psychiatric findings, greater
BSP retention (the remainder of liver function
tests being essentially equal), more acute and
chronic changes on liver biopsy and the appear-
ance of more serious sequelae. Kern, Mikkelsen
and Turriff11 found that of 35 patients with
biopsy-proven hyaline necrosis, 37 per cent died
during that hospitalization (in contrast to only
nine per cent of 228 patients in whom hyaline
changes were not found). This poor prognosis
extended to those patients in whom the hyaline
necrosis was morphologically not typical and
limited to only a few cells.

On the other end of the spectrum there have
been reported five cases of “A.A.H. without
jaundice,” only two of whom had Mallory’s hya-
line and none of whom died. Green et al12 stud-
ied 50 cases, only two of whom died (one of
staphylococcal pneumonia and one from sepsis)
and it is their recommendation that the diagnosis
be reserved for chronic alcoholics with a history
of drinking up to the time of admission who pre-
sent the clinical picture of acute hepatic insuf-

480

JOURNAL MSM A

TABLE 5

CAUSE OF DEATH AND COMPLICATING DISEASES

Interval in Days Between

Patient Age Cause of Death Admission and Death

A.C.B. 56 Hepatic coma, GI bleeding, fresh myo- 2

cardial infarction

W.H.T. 33 Hepatic coma, pancreatitis, pericarditis, 14

renal failure

C.E.R. 68 Hepatic coma, pulmonary edema 1

L.J.R. 51 Hepatic coma 7

R.D.B. 57 Hepatic coma, pseudomonas septicemia 7

C.B.M. 43 Hepatic coma, G.I. bleeding 35

T.D. 50 Hepatic coma 1

H.P. 55 Hepatic coma 8

E.E.B. 59 Hepatic coma 28

H.M. 59 Hepatic coma, pneumonia 24

G.R. 50 Hepatic coma, pneumococcal pneumonia, 2

perforated gastric ulcer with peritonitis,
subarachnoid hemorrhage, portal vein
thrombosis

E.A. 46 Hepatic coma 11

ficiency and show fat, necrosis, inflammation, and
Mallory bodies on liver sections.

In the present series of 32 patients, twenty of
whom survived and 12 of whom expired, no
significant difference was observed in the presence
or absence of or prevalence of Mallory bodies in
the histologic sections. In addition to the vari-
ability of classification of the syndrome of A.A.H.
in the literature, there is also some variance as to
what constitutes a Mallory body. The hyaline
bodies are variously described as rounded or
irregular hyaline masses, as being initially finely
granular and later condensed and homogenous, as
lumpy, as a course acidiophilic meshwork-often
perinuclear, as ramified hyaline material or re-
fractive hyaline bodies near the nucleus, or orig-
inally by Mallory, as a coarse hyaline meshwork.

Both the discrete rounded bodies and the
hyaline degenerative changes were accepted as
Mallory bodies for the purpose of this review.
These changes were excluded from other “hya-
line-appearing” artifacts such as free extracel-
lular hyaline cells with uniformly-staining eosino-
philic cytoplasm, and the presence of condensed
eosinophilic cytoplasm seen in cells occupied
primarily by fat. These changes of alcoholic
hyaline are thought by most to represent swollen
altered mitochondria.

The clinical picture consisted of, for the most
part in our series, a known alcoholic, average
age 48.15 years, presenting with fever, jaundice,
ascites and gastrointestinal bleeding. The ascites
and bleeding were more ominous signs, and as

would be expected, were less common in the pa-
tients who survived.

On physical examination, these patients, in
addition to the fever, jaundice and ascites were
found to have hepatomegaly, neuropsychiatric
signs, and abdominal tenderness. These altera-
tions do not differ from those found in alcoholics
with chronic liver disease without superimposed
A.A.H. The fever and abdominal tenderness
(complaints of abdominal pain were not nearly
so prominent in this series as are present in most
reviews of this entity) have been emphasized in
the literature as being characteristic of this entity.
Though fever and abdominal tenderness when
found in an alcoholic should certainly bring
to mind the syndrome of A.A.H., the number
of other conditions frequently responsible for
such would prevent these findings from being
considered characteristic. The point has been
made12 that because of the frequent presenting
clinical picture of abdominal pain, nausea, vomit-
ing, fever and leukocytosis these patients are often
misdiagnosed as that of an acute surgical abdo-
men.

There have been various attempts in the litera-
ture to incriminate certain laboratory abnormali-
ties as having characteristic or prognostic signifi-
cance. Anemia, reticulocytosis, and leukocytosis
have been reported in 60-80 per cent of cases.3
Anemia and leukocytosis, both quite mild, were
prevalent in our patients, being slightly more
frequent in the non-survivors. Reticulocyte counts
were not obtained frequently enough for this to

SEPTEMBER 1970

481

ALCOHOLIC HEPATITIS / McKell et al

be a valid consideration. We did not find, as did
Phillips and Davidson,5 that the degree of leuko-
cytosis paralleled the severity of illness.

The biochemical aspects of renal manifestations
in liver disease include oliguria, hypotension,
azotemia, hyponatremia, and hyperkalemia. Hec-
ker and Sherlock13 have proposed that the degree
of hyponatremia has prognostic value: that so-
dium levels of less than 130 are serious and that
those of less than 120 are ominous.

In our series, the nonsurvivors had an inci-
dence of azotemia six times that of the survivors,
however only one of these had a blood area nitro-
gen greater than 60 mg. per cent. As with almost
any disease or syndrome, one would certainly
expect a higher mortality rate with an accom-
panying rise in the BUN, and A.A.H. is no dif-
ferent in that respect.

Also the incidence of hyponatremia in the pres-
ent series was 83 per cent in the non-survivors as
compared to 35 per cent in those who survived.
There were eight patients who had or developed
a serum sodium of 120 mEq/L or below, and
none of these eight survived. In three of these
patients the BUN was normal. The degree of
hyponatremia, if the serum sodium was less than
130, was the most definite laboratory indicator
of a poor outcome of any test we obtained, how-
ever this apparently is true of chronic alcoholic
liver disease in general, regardless of whether
A.A.H. is superimposed.

HYPERBILIRUBINEMIA

Hyperbilirubinemia was almost universal, in
fact it has been listed as criteria for inclusion in
the syndrome. Phillips and Davidson5 felt that the
degree of elevation of the icterus index may be
prognostic and it may be noted in our series
that six out of the seven patients whose total
serum bilirubin exceeded 15 mg. per cent died.
The SGOT has been said, if elevated, to be the
best laboratory test in predicting the presence of
A.A.H.14 It is known, that though there is usually
a greater degree of cellular necrosis in A.A.H.
that the serum SGOT is only modestly elevated.
It has been postulated that in hyaline necrosis,
the cells “die slower.”16 We were quite surprised
at the rather low frequency (40 per cent in sur-
vivors and 25 per cent in non-survivors) of SGOT
elevation in our series. In only four cases did we
find the SGOT to be 200 units or greater, two of
these died after one and two days hospitalization
each and in one there was noted at autopsy a
fresh myocardial infarction. We found as have
others1- 5’ 15 that an elevation of the alkaline

phosphatase was not the rule. In the series of
Beckett et al9 however, the laboratory picture!
was described as that of “liver cell damage with
some intrahepatic obstruction,” implying that
there is typically an elevation of both the SGOT .
and alkaline phosphatase. It is felt that the
hypoalbuminemia and hyperglobulinemia, rather
than being representative of this rather acute
syndrome, simply reflect the degree and chronic-
ity of the underlying liver disease. It is well
established that these two protein abnormalities
plus “beta-gamma” bridging in the protein elec-
trophoresis strip are classical findings in hepatic
cirrhosis.

PROTHROMBIN TIME

It had been our experience with other types of
serious and occasionally terminal liver disease,
including that due to alcohol abuse, that the
prothrombin time was the most valuable tool in
our laboratory (prior to the illness reaching the
degree of severity at which significant hyponatre-
mia develops) in predicting the immediate prog-
nosis. Harinasuta et al3 found in their series of
175 patients with A.A.H. that the degree of
hypoprothrombinemia was a useful prognostic
tool, however Ugarte et al16 noted that the mag-
nitude of alteration in the prothrombin time did
not differ from that found in the general alcoholic
population. We found prolongation of the pro-
thrombin time in approximately one-half of the
cases in both the survivors and non-survivors,
making this neither an almost universal labora-
tory abnormality nor one of significant prognostic
import.

So in addition to presenting with fever, jaun-
dice, ascites, gastrointestinal bleeding, hepatomeg-
aly with abdominal tenderness and some element
of neuropsychiatric aberration, our “typical”
middle-aged alcoholic will be found to have ane-
mia, leukocytosis, and hyperbilirubinemia. If he
be one who is ultimately to die during this hos-
pitalization, he may also be found to have azote-
mia and hyponatremia and the above-mentioned
hyperbilirubinemia to be in excess of 15 mg. per
cent.

ADEQUATE MANAGEMENT

There is insufficient space to undertake a de-
tailed discussion of management of A.A.H., how-
ever an adequate program must include the fol-
lowing: bed rest for what may be a rather pro-
longed period of time, until evidence of acute
hepatocellular injury subsides; adequate diet and
vitamin replacement. The diet should provide ad-
equate calories, proteins, and fat to make the
diet palatable. A regular diet in which the pa-

482

JOURNAL MSM A

tient has some choice in menu selection and in
which fried and greasy foods are kept to a mini-
mum, serves the purpose. Folate and Vitamin
B6 depletion are known to interfere with DNA
and enzyme synthesis17 and should therefore be
replaced in therapeutic amounts.

Salt restriction, usually 200-500 mg. sodium,
may be indicated if fluid retention exists. The
addition of potassium supplementation and
Vitamin K may also be required. Hepatic coma,
gastrointestinal bleeding, superimposed infections,
and renal complications or combinations thereof
must be managed accordingly and with great
care, for the complicating presence of any one
of these greatly worsens the prognosis in A.A.H.
The causes of death in our twelve patients who
expired are shown in Figure 5. As can be seen,
hepatic coma was the sole cause of or a major
contributing factor in the death of each of the
twelve patients. Major infections were present in
three, severe gastrointestinal hemorrhage in two,
and renal failure in only one.

GLUCOCORTICOID USAGE

The use of glucocorticoids in the treatment of
inflammatory liver disease remains controversial.
Because of the mesenchymal cell proliferation18
and inflammatory response in A.A.H. , adrenal
steroids may well have a place in management
here. Short-term courses of glucocorticoids may
be of some benefit in reducing the anorexia and
allowing correction of the existing protein and
vitamin depletion, thereby promoting liver cell
regeneration.

If one elects to use these drugs, he must cer-
tainly keep in mind the influence of steroids on
the precipitation of bleeding peptic ulcers, the
presence of complicating infections, and the false
sense of security one might obtain from the more
rapid decline in serum bilirubin and sense of well-
being produced in the patient. The Copenhagen
study group for liver disease,19 in investigating
the use of corticosteroids on survival of patients
with cirrhosis, came to the following preliminary
conclusions:

1. Prednisone worsens the prognosis in patients
with persistent ascites.

2. In female patients without ascites, predni-
sone treatment improves the prognosis.

3. In the remainder, primarily male alcoholics,
the prognosis is probably not influenced by the
use of prednisone.

Steroids were used in six of our patients, in
four of the survivors and in two who died. In a
retrospective view of such a small sample, cer-
tainly no conclusions can be drawn.

What is needed in the complete management

of these patients, especially those who progress
to either chronic cirrhosis or fulminant hepatic
failure and death, is the prevention of mesenchy-
mal reaction and fibrosis, removal of toxic factors
from the blood, hepatic support, and the addition
of deficient factors to the circulation while the
patient is essentially without a liver, thereby allow-
ing time for hepatic regeneration. Certain rather
involved programs which may well offer much in
the future management of these patients are per-
fusion of the patient’s blood through an isolated
pig liver, cross circulation with human volunteers,
exchange blood transfusion, plasmapheresis, and/
or transplantation. At the present time, only
plasmapheresis seems to be practical enough to
be considered for use in the small private hospital.

SUMMARY

Thirty-two cases of acute alcoholic hepatitis
were presented and the clinical, laboratory and
histologic features were discussed. The mortality
rate in the series was 38 per cent. The typical
picture is that of a known alcoholic, average age
48.15 years, presenting the fever, jaundice, ascites
and gastrointestinal bleeding, who upon examina-
tion is found to have hepatomegaly, neuropsychi-
atric signs and abdominal tenderness. Those who
survived had a lesser incidence of azotemia, hy-
ponatremia, marked hyperbilirubinemia (15 mg.
per cent), hyperglobulinemia, and elevation of
the alkaline phosphatase. Prognostically, there
was noted no significant histologic features, speci-
fically the authors did not find any real difference
in the incidence of Mallory bodies between sur-
vivors and non-survivors.

838 Lakeland Drive (39216) (Dr. McKell)

Acknowledgements: The authors wish to thank Dr.
Catherine G. Goetz for her invaluable assistance in re-
viewing the histologic sections with us.

REFERENCES

1. Popper, H.; Szanto, O. B. and Parthasarathy, M.:
Florid Cirrhosis. A Review of 35 Cases, Am. J. Clin.
Path. 25:889, 1955.

2. Betrand, L.; Reynolds, T. B. and Michel, FI.: Lame-
crose hyaline sclerosante du foie alcolique (entite:
anatomo-clinique et hemodynamique. Son potentiel
cirrhogene), Press. Med. 74:2837, 1966.

3. Harinasuta, U.; Chomet, B.; Ishak, K. and Zimmer-
man, H. J.: Steatonecrosis-Mallory Body Type, Medi-
cine 46: 141, 1967.

4. Hall. E. M. and Morgan, W. A.: Progressive Alco-
holic Cirrhosis: Clinical and Pathological Study of
68 Cases, Arch. Path. 27:672, 1939.

5. Phillips, G. B. and Davidson, C. S.: Acute Hepatic
Insufficiency of the Chronic Alcoholic, Arch. Int.
Med. 94:585, 1954.

6. Edmondson, H. A.; Peters, R. L.; Reynolds, T. B.
and Kuzma, O. T.: Sclerosing Hyaline Necrosis of
the Liver in the Chronic Alcoholic: A Recognizable
Clinical Syndrome, Ann. Int. Med. 59:646, 1963.

7. Mallory, F. B.: Cirrhosis of the Liver: Five Differ-

SEPTEMBER 1970

483

ALCOHOLIC HEPATITIS / McKell et al

ent Types of Lesions From Which It May Arise,
Bull. Johns Hopkins Hosp. 22:69, 1911.

8. Steiner, P. E. and Higginson, J.: Definition and
Classification of Cirrhosis of the Liver, Acta Un.
Int. Cancr. 17:581, 1961.

9. Beckett, A. G.; Livingston, A. V. and Hill, K. R.:
Acute Alcoholic Hepatitis, Brit. Med. J. 2:113, 1961.

10. Rice, J. D., Jr. and Yesner, R.: The Prognostic
Significance of So-called Mallory-Bodies in Portal
Cirrhosis, Arch. Int. Med. 105:99, 1960.

11. Kern, W. H.; Mikkelsen, W. P. and Turrill, F. L.:
The Significance of Hyaline Necrosis in Liver Bi-
opsies, Surgery, Gyn. & Ob. 129:749, 1969.

12. Green, J.; Mistilis, S. and Schiff, L.: Acute Alcoholic
Hepatitis. A Clinical Study of Fifty Cases, Arch.
Int. Med. 112:67, 1963.

13. Hecker, R. and Sherlock, S.: Electrolyte and Cir-
culatory Changes in Terminal Liver Failure, Lancet
2:1121, 1956.

14. Wessler, S. and Avioli, L. V.: Alcoholic Hepatitis,
JAMA 203:865, 1968.

15. Schaffner, F.; Loebel, A.; Weiner, H. A. and Barka,
T.: Hepatocellular Cytoplasmic Changes in Acute
Alcoholic Hepatitis, JAMA 183:343, 1963.

16. Ugarte, G.; Iturriaga, H. and Insunza, I.: Some Ef-
fects of Ethanol on Normal and Pathologic Livers, 1
in Progress in Liver Diseases, Vol. 1; Ed. by Popper,
H. and Schaffner, F., New York, Grune and Strat-
ton, 1970, p. 355.

17. Leevy, C. M.: Clinical Diagnosis, Evaluation and
Treatment of Liver Disease in Alcoholics, Fed. Proc.
26:1474, 1967.

18. Ien Hove, W.; Cherrick, G. and Leevy, C. M.:
Morphologic and Enzymatic Changes Induced by
Ethanol, Clin. Res. 13:262, 1965.

19. Copenhagen Study Group for Liver Diseases: A
Controlled Trial of Prednisone Treatment in Cir- 1
rhosis. Effect of Prednisone on the Survival of Pa-
tients With Cirrhosis of the Liver, Lancet 1:119,
1969.

OUT OF THIS WORLD

The exobiologists whose field is the science of extraterrestial
life forms are divided as to the presence of intelligent beings on
planets in the universe. Consider these two diametrically opposite
views:

“There is nobody on Mars, and I am positive. It hasn't shown
up on my teenage daughter’s telephone bill.”

“There is, without question, intelligent life on the moon. How
do I know? Well, you don’t see them spending $24 billion to
come down here to pick up rocks.”

484

JOURNAL MSMA

Twenty -Seven Months of
Chemoprophylaxis for Prevention of

Tuberculosis in Mississippi

LEE R. REID, M.D.
Jackson, Mississippi

No practical method is available at the present
time that will directly prevent the first infection
by the tuberculosis bacillus. This can only be at-
tempted indirectly by keeping the uninfected indi-
vidual from contact with active cases through re-
duction of the number of such cases available for
contact. Therefore, complete tuberculosis control
will have to be directed, at present, toward pre-
venting non-communicable, primary cases of tu-
berculosis from converting into reactivated cases
who transmit the disease. Another facet of the
problem is to protect the uninfected person from
reactivated cases among those who had been con-
sidered, erroneously, to be inactive.

Both of these problems can be handled, in a
majority of instances, by the simple use of isoni-
azid, prophylactically. This drug, if taken in prop-
er doses regularly for 12 months, will prevent
the primary disease from progressing to the clini-
cal stage (reactivation, secondary or adult tuber-
culosis) in almost all cases. It will also prevent
reactivation of inactive disease in most instances.

Late in 1967, a committee from several organi-
zations interested in tuberculosis published a re-
port dealing with prevention of tuberculosis by
the use of isoniazid.1 In November, 1967, a
state-wide program was instituted in Mississippi
by the Tuberculosis Control Unit of the Division
of Preventable Disease Control of the Mississippi
State Board of Health. This was reported in July.
1968. 2 The present article is to report the results
of this program from November, 1967, to Feb-
ruary, 1970.

From the Tuberculosis Control Unit. Division of Pre-
ventable Disease Control. Mississippi State Board of
Health, Jackson.

Briefly, our program of chemoprophylaxis is
based upon research by the U.S.P.H.S.3 They
found that isoniazid was successful in preventing

During 27 months between 1967 and 1970,
more than 14,500 high risk patients in Mis-
sissippi were given isoniazid prophylactically
for tuberculosis. The program was carried
out by county health departments under the
direction of the Tuberculosis Control Unit
of the Division of Preventable Disease Con-
trol of the State Board of Health. Among
these patients, no proven cases of tuber-
culosis developed in those who took isoni-
azid as directed. Thirty-two proven cases
were found; 11 of these did not take the
drug as directed and the other 21 were found
to have developed the disease before the
prophylactic therapy was initiated.

the occurrence of active, clinical tuberculosis
among high risk groups in around 60 per cent of
their cases. This extensive work showed that of
70,000 people forming the basis of the study,
698 developed active clinical tuberculosis. Out of
the 698 proven cases, 502 were among those re-
ceiving placebo and only 196 were among those
who received isoniazid. This clearly indicated its
value. However, the drug failed to protect 196 of
the patients. There is little doubt that a large per-
centage of the failures were among those who did
not take the drug regularly nor for the prescribed
length of time. The protection that was afforded

48 5

SEPTEMBER 1970

CHEMOPROPHYLAXIS / Reid

in such a high risk group amply justifies the pro-
cedure.

Chemoprophylaxis is carried out by giving iso-
niazid at the rate of 300 milligrams per day to
adults and dosage of 5 milligrams per pound (10
milligram per kilo) to children, daily for one year.

When our program was launched in November,
1967, we were not able to put the information on
punch cards for data processing. Because of this,
the individuals reported here are included in only
one group of reasons for prophylaxis (categories).
These categories were listed in priority order and
the highest one applicable was used. Our choices
as to the priority order, by our own admission,
are open to question. It was decided, however,
that to prevent confusion, we would not change
these priorities until we could process the data by
machine. Most of the persons in the series could
be included in two or more categories, but to
try to do this without the aid of machine process-
ing would have presented difficulties we were not
prepared to handle. Beginning February 1, 1970,
information has been put on punch cards and will
be tabulated at regular intervals in the future.

From Novmeber 1, 1967, to January 31, 1970,
14,633 persons were started on chemoprophylaxis

TABLE 1

REASONS FOR DISCONTINUATION OF
ISONIAZID

From 11/1/67 to 9/1/69, 3,532 persons terminated
chemoprophylaxis. Of this number 2,193 completed 12
months of the drug. The following are the reasons for
termination of the drug by the other 1,339 cases.

1. Uncooperative 720

2. Lost to follow-up 291

3. Drug reaction (real or imaginary) 90

a. Allergy (skin rash) 27

b. Nausea 27

c. Dizziness 16

d. Gains weight 5

e. “Kidney trouble” 5

f. “Nervousness” 3

g. “Pleurisy” pain 3

h. Rapid pulse 1

i. Hypertension 1

j. “Fever” 1

k. Epileptic seizures (?) 1

4. Discontinued on advice of private physician 88

5. Died of unrelated causes 61

6. Put on chemotherapy 57

7. On advice of Tuberculosis Control Unit 24

8. Religious convictions 4

9. Others 4

in Mississippi. This is at the rate of 624.3 per
100,000 population, based on 1968 population
estimate of 2,344,000 for the state.4

The categories included in our program (all
those recommended as high risk individuals in
the original report) are as follows:

1 . Household contacts

2. Positive tuberculin below age of 20

3. Tuberculin converter

4. Ex-patient (diagnosed case) with inade-
quate or no previous chemotherapy with isoni-
azid.

5. X-Ray changes suggestive of tuberculosis
with positive tuberculin.

6. Pregnancy

7. Special clinical situations with positive tu-
berculin such as corticosteroid treatment, gas-
trectomy, leukemia or Hodgkins’ disease, unstable
severe diabetes, or silicosis.

8. Measles or whooping cough with positive
tuberculin.

9. Positive tuberculin, age 20 years or over
with negative x-ray.

Category 9 required at least a 10 mm Mantoux
reaction or Grade 3 Heaf; all others, 5 mm Man-
toux or grade 2 Heaf.

In the categories listed above, only two need
to be discussed. The other seven are self-explana-
tory.

Household Contacts (Category No. 1)

Persons in household contact with an active
case of tuberculosis are in the greatest danger of
contracting the disease. There were two suggested
methods for managing household contacts men-
tioned in the original publication.1 2 3 4 5 6 7 8 9 First, that all
members of the household be skin tested and the
positive reactors be given isoniazid. The negative
reactors were to be retested at three month inter-
vals and the ones that converted to positive were
placed on the drug. Second, offered as an alterna-
tive plan, was to place all members of the house-
hold on isoniazid, regardless of the result of the
tuberculin test. This latter policy was adopted for
two reasons. First, our limited nursing personnel
would, in many instances, not be able to repeat
skin tests at regular intervals. Second, it would
have been difficult to explain to some of our fami-
ly groups why some of them would have to take
the drug and others would not. The lack of under-
standing, we feared, would contribute to lagging
interest and poor cooperation. The low degree of
toxicity of isoniazid allowed us to temper the ideal
with the practical and give it to some who might
not actually need it. Household contacts had
14 x 17 chest films at three month intervals dur-

486

JOURNAL MSM A

TABLE 2

NEGATIVE SPUTUM INDIVIDUALS CHANGED FROM CHEMOPROPHYLAXIS

TO CHEMOTHERAPY

1

6

2

H . 2

6

Unk.

Unk.

X

Suspicious X-ray

3

84

1

H . 3

7

X

X

X

Death Certificate (?)

11

18

1

H • 3

7

Unk.

Unk.

X

X

Suspicious X-ray

12

24

9

H . 4

6

X

X

X

X

Suspicious X-ray

13

28

9

H • 3

-1

X

X

X

X

Suspicious X-ray

16

19

3

H . 1

14

X

X

X

Suspicious X-ray

17

28

1

H . 3

6

X

Unk.

Unk.

X

No recent X-ray (Hurricane)

18

7

1

9**

5

X

Unk.

Unk.

X

No recent X-ray (Hurricane)

20

28

1

M.12

8

X

X

Private M.D. Order (Need?)

22

16

1

H.4

2

X

X

X

X

Suspicious X-ray

24

69

1

H . 2

-1

X

Unk.

Unk.

X

No recent X-ray (Hurricane)

25

51

5

M .15

3

X

X

X

Private M.D. Order (Need?)

26

63

5

H . 2

-1

X

X

X

X

Suspicious X-ray

27

24

9

M. 15

-1

X

X

X

Suspicious X-ray

28

14

2

H.4

1

X

X

X

Suspicious X-ray

30

9

1

Neg.

9

X

X

X

X

Suspicious X-ray

32

71

9

H.3

4

X

X

X

Suspicious X-ray

33

29

1

H.l

-1

Unk.

Unk.

X

X

Suspicious X-ray

40

5

2

H.4

1

X

X

X

Suspicious X-ray

45 '

4

2

H.3

-1

X

X

X

Suspicious X-ray

50

41

9

M .10

-1

X

X

*

X

Suspicious X-ray

52

1

1

H.l

7

X

X

X

Suspicious X-ray

53

46

9

H.3

-1

X

X

X

X

X

Suspicious X-ray

56

5

2

H.3

1

X

X

X

Suspicious X-ray

57

53

9

H.4

3

X

Neg.

Private M.D. Order (Need?)

* Record lost in Hurricane Camille

SEPTEMBER 1970

487

CHEMOPROPHYLAXIS / Reid

ing the period, if possible. If not, they were made
at least at beginning and end of prophylaxis.

Positive Tuberculin (10 mm. reaction or grade
III Heaf) Age 20 or Over With Negative X-Ray
(Category No. 9)

This category deserves special mention as the
one composed of people with a Mantoux of 10
mm or Heaf Grade 3 tuberculin test but with a
negative 14x17 chest film. Minor calcific deposits
in the hilar areas and a few flecks of calcium in
the lung fields are usually disregarded and cases
showing them are read as negative. This attitude
is due to the prevalence of histoplasmosis in this
area of the country. The first invasion of the body
with mycobacterium tuberculosis may be on a very
minor scale. The residuals of this infection may
be so small as to be undetectable by x-ray. In
these cases, the evidence of the disease will be
represented only by a positive reaction to tuber-

culin. Still, these persons with “negative” chest
films are in some danger of reactivation of the
tiny lesion, resulting in a clinical and communi-
cable disease.

Figure 1 shows the number of individuals
treated by category based on 14,633 persons
receiving chemoprophylaxis from November,
1967 to February, 1970.

As expected, category No. 9, those individuals
with a 10 mm or over Mantoux or grade 3 or over
Heaf tuberculin test but without x-ray evidence
of disease, composed our largest group with 50.0
per cent. Household contacts, category No. 1,
rated second with 27.0 per cent. Category No. 2,
a positive tuberculin below the age of 20 years,
rated third with 12.6 per cent.

Figure 2 shows distribution by age. This data
was based on persons terminated between Novem-
ber 1, 1967, and September 1, 1969, numbering
3,532. It is noted that the groups including the
teenagers made up 22.2 per cent of the total num-
ber. The middle-aged (41 to 60 years) group

Figure 1. Indications for prophylaxis in 14,633 persons who received isoniazid be-
tween 11/1/67 and 2/1/70.

488

JOURNAL MSM A

500

459

Figure 2. Ages of 3,532 persons whose chemoprophylaxis was terminated between
11/1/67 and 9/1/69.

showed 30.7 per cent.

Table 1 shows reasons for discontinuation of
isoniazid. An analysis of the table shows that of
3,532 whose drug was terminated between No-
vember 1, 1967, and September 1, 1969, 2,193
or 62.1 per cent took the whole year of medica-
tion.

Reasons for Discontinuation of Isoniazid

1. Uncooperative:

The greatest handicap to success in chemopro-
phylaxis are those people who refuse to take the
drug as directed. Of the 3,532 persons upon whom
treatment had been terminated, 720 were unco-
operative and took the drug issued to them only
for a few days or weeks. Others took it so irregu-
larly as to be of questionable benefit. This was
not unexpected. Even in treatment of active dis-
ease, when the patient knows recovery istelf de-
pends upon taking the drug, it is difficult to get
some patients to cooperate in the matter of self-
administered treatment at home.

Figure 3 shows the length of time that the
3,532 cases who were terminated between No-
vember 1, 1967, and September 1, 1969, took
the drug. This shows that the third and sixth
month of the treatment year seem to be the crucial
time for giving up treatment. This, however, prob-

ably reflects the fact that many cases were con-
tacted at three month intervals when the next
three months supply of the drug was to be issued
and an x-ray made. At this time, the nurses
learned that the patient was not taking the isonia-
zid. Two thousand one hundred ninety-three cases
(62.1 per cent) endured to the end and finished
a complete 12 months of continuous medication.

It will be noted that most ot the patients who
finished at least six months of isoniazid went on
and took the drug for the whole year. The greatest
number of “dropouts” were during the first 6
months.

2. Lost to Follow-up:

Two hundred and ninety-one people moved and
could not be located for further treatment and
followup.

3. Drug Reactions:

Ninety had drug reactions. Unfortunately, com-
plaints listed in this group are largely unconfirmed.
They were the reasons given to the nurses when
individuals were confronted with the fact that
they had not been in for a refill of the isoniazid
order then due. A few skin rashes were confirmed
by the nurses. Most of the other complaints were
probably excuses given by those who could neither
comprehend the necessity for nor the principles
of prophylaxis.

SEPTEMBER 1970

489

CHEMOPROPHYLAXIS / Reid

4. Drug discontinued on advice of private phy-
sician:

In 88 instances the family physician objected
to the use of the drug for various reasons, the
most frequent being the result of his patient com-
plaining to him of bizarre symptoms in order to
escape taking the medication. Some physicians,
not being familiar with the drug and knowing that
it was being given prophylactically, simply felt
it was probably not worthwhile. One case was
hospitalized and a liver abnormality was found.
Proof that it was due to the isoniazid was rather
weak and sketchy, but the drug was not given
to this patient after that, at this physician’s re-
quest.

Not all the physicians concerned were con-
tacted. We found that many people who had quit
taking the drug, when questioned by the nurse,
gave the family physician’s objection as an excuse.
In a substantial number of instances, when the
private physician was contacted, it was found that
the patient had misrepresented the facts.

5. Died of unrelated causes:

Sixty-one persons died while under prophylaxis,
from unrelated causes.

6. Put on chemotherapy:

Between November 1, 1967, and February 1,
1969, 57 persons of the 14,633 taking chemo-
prophylaxis were put on chemotherapy for various
reasons. The subject is discussed later in this re-
port under “Individuals shifted from chemopro-
phylaxis to chemotherapy.’*

7. On advice of Tuberculosis Control Unit:

Twenty-four people were taken off chemopro-
phylaxis after being started on it by error; an
illustration being some housheold contacts who
were put on the drug when the index case was

Figure 3. Months on chemoprophylaxis for 3,532
persons whose treatment was terminated between
11/1/67 and 9/ 1/69.

found to have been diagnosed tuberculosis on
basis of an error in laboratory reporting, etc.

8. Religious convictions:

Four persons started the drug, then gave it up
because of religious reasons.

9. Others:

Three individuals with mental retardation were
felt to be incapable of self-medication.

One case was “incapable of swallowing the
medication because of mental condition.”

Shifted From Chemoprophylaxis to Chemother-
apy (“Failures”)

The success of chemoprophylaxis can be judged
by the number of people who develop tuberculosis
while taking the drug or after completion of the
course of chemoprophylaxis. We have followed
most of our people for a relatively short period
after completion of prophylaxis. Only three were
found to require chemotherapy after one year of
chemoprophylaxis. Two of these individuals, a
mother and daughter, although they were on
record as having taken INH for 12 months, when
questioned admitted that they took the drug only
when they “thought of it.” Both had positive spu-
tum. The daughter developed moderately advanced
tuberculosis while under observation, was treated
at Sanatorium with complete clearing of the in-
filtration. The mother, although the organism was
reported as being found in her sputum, never
showed any evidence of disease by x-ray but
received a regular course of chemotherapy. Since
the reliability of those two patients leaves much to
be desired, it is likely that the sputum specimens
were mixed up and both the positive ones were in
reality from the daughter who unquestionably
had the disease.

Another 19-year-old girl was put on chemo-
therapy one year and two months after chemo-
prophylaxis was started, but records show she
definitely did not take much of the isoniazid and
was not proven to have tuberculosis bacteriologi-
cally. She had a suspicious x-ray change and was
put on chemotherapy to be on the safe side. All
other cases reported were shifted from chemo-
prophylaxis to treatment while they were sup-
posedly taking isoniazid.

No information was available in 1967 as to
how long an individual had to be on prophylaxis
before the appearance of active disease denoted
a failure of chemoprophylaxis. When our pro-
gram was set up, a decision was made that any
individual who was receiving, or had received,
isoniazid when circumstances dictated that multi-
ple drug therapy was advisable would be tagged
as a “failure.” This was done regardless of how

490

JOURNAL MSM A

short a period of time the chemoprophylaxis medi-
cation had been administered.

Between November 1, 1967, and January 31,
1970, 57 people were shifted from prophylaxis
to treatment. Of these, 32 were diagnosed on the
basis of the culturing of M. tuberculosis from the

Figure 4. New active cases 1957-1969.

sputum or gastric washings. The other 25 were
not confirmed bacteriologically. These latter will
be considered first. Table No. 2 shows a break-
down of these individuals.

The following points should be brought out
in explanation: Case No. 3, an 84-year-old wom-
an, a household contact in a very unreliable
family died in a local hospital after having taken
the drug irregularly for seven months before
death. The death certificate showed death due to
“pleurisy with effusion, right ( tuberculosis? ) This
diagnosis is accepted with reservations. She re-
ceived multiple drug therapy for a few days while
in the hospital before death.

Three (Nos. 17. 18, and 24) were unable to
have follow-up x-ray films due to disruption of
services as the result of hurricane Camille. In one
(No. 18) records of the tuberculin test were lost
for the same reason. Three (Nos. 20, 25, and 57)
were put on multiple drug therapy at the request
of their private physician. Although in all three
of these people, in our opinion, there was very
little justification for this, we honored their doc-
tor’s recommendations.

Seven (Nos. 12, 13, 22, 28, 30. 52, and 53)
were put on chemotherapy upon admission to the
Sanatorium as a routine measure.

Two (Nos. 24 and 26) showed atypical orga-
nisms of Runyon Group III on sputum culture.
One (No. 53) showed atypical organisms of Run-
yon Group II on sputum culture. In all three in-
stances, chemoprophylaxis had been in effect

less than one month and all three were routinely
put on multiple drug therapy.

Eighteen (Nos. 11, 12, 13, 16, 17, 18, 22, 25,
26, 27, 30, 32, 33, 40, 45, 50, 53, and 56) showed
x-ray evidence suggestive of active disease such
as soft appearing shadows, cavitation, etc. on
the first film. These films were taken usually with-
in a few days to one month after the start of
chemoprophylaxis. No one of this group was ever
found to have M. tuberculosis in sputum.

Category No. 9 is actually supposed to be cases
with a grade 3 or 4 Heaf test or a 10 mm or over
Mantoux with negative x-ray. In the seven people
in this category, four of them (Nos. 13, 27, 50,
and 53) had taken isoniazid for less than one
month before the first x-ray showed evidence of
disease. These had no other category to be put
into so were left in category No. 9. Two (Nos.
12 and 32) had x-ray films negative on first
films, but developed lesions in the lung at a later
date. The other patient in category No. 9 (No.
57) had a negative x-ray all along but because of
a strongly positive Heaf test, a local physician re-
quested that she be placed on multiple drug ther-
apy.

Although none of these 25 people were proven
to have tuberculosis by culturing the organism,
there remained the probability that there may
have been insufficient efforts to obtain sputum
from some of them. This may have been espe-
cially true in the case of the seven children in the
group. With this in mind, the records were
searched for ones with negative sputum but in
whom the following criteria were present that in-
dicated that active disease was present. We looked
for someone who had a significantly positive tuber-
culin and who took the isoniazid regularly for at
least two months. Were there any that, in spite
of the above and with a previously negative x-ray
film or with a stable appearing lesion, developed
a suspicious lesion or had evidence of instability
of a lesion present? In such a case did the x-ray
clear upon institution of multiple drug therapy
within a reasonable length of time?

Admittedly the above are rather stringent re-
quirements for diagnosis of active disease but
it would be hard to eliminate any of them and feel
justified in using the remaining as evidence against
the effectiveness of chemoprophylaxis.

We were unable to find such among these 25
persons. In evaluating these 25 people then, it is
our belief that not a single one had been a failure
of chemoprophylaxis.

Thirty-two cases were put on therapy because
of the finding of M. tuberculosis in the sputum.
Of these cases, 1 1 were found to have taken very

SEPTEMBER 1970

491

CHEMOPROPHYLAXIS / Reid

little of the isoniazid. Of the 21 other cases of
positive sputum, all of them were found to have
had active disease at the time the chemopro-
phylactic drug was started. All of these 21 had
the medication started when the positive tuber-
culin was discovered. The sputum sent in to the
laboratory at or about the same time the tuber-
culin test was read was reported several weeks
later to be positive for M. tuberculosis.

On the basis of all findings then, there was not
a single case out of the 14,633 on chemoprophy-
laxis that developed proven active disease pro-
vided the patient took the isoniazid as directed.
One hesitates to report such a perfect result. In a
program such as ours conducted by 82 different
county health departments of varying ability and
interest, some mistakes may have been made in
the records or perhaps in the reporting of our
experience.

A question naturally arises as to how many of
these 14,633 people would have developed tuber-
culosis if no chemoprophylaxis had been given.
We know that in the United States in 1968, 21.3
new active cases per 100,000 appeared in the
general population.5

The people we are considering are high risk
ones. We would therefore expect a larger num-
ber per 100,000 to develop tuberculosis. The
U.S.P.H.S. study was conducted on a similar high
risk group. Out of 30,779 people that received
placebo instead of isoniazid after having been
followed for over an average of 7.5 years, 502
cases of tuberculosis developed.

This would give an average annual case rate of
217.5 cases per 100,000 population. Therefore,
in their high risk group, tuberculosis was 10 times
more frequent than in the general population.

In regard to the Mississippi people, our figures
cannot be directly compared to those of the
U.S.P.H.S. since their criteria for inclusion in
the study was a 10 mm positive P.P.D. (grade 3
Heaf). In our individuals, a 10 mm positive P.P.D.
(grade 3 Heaf) was required only in category No.
9. In fact, some of the household contacts (cate-
gory No. 1 ) had negative tuberculin tests.

In the 2,193 people that finished one year of
chemoprophylaxis, no cases of tuberculosis de-
veloped. Out of 12,440 persons not having
finished one year of chemoprophylaxis, 32 de-
veloped tuberculosis. This would be an average
of 114.3 per 100,000 per year. Although this
rate was only around half that reported in the
U.S.P.H.S. survey, it is still 5.4 times the rate
for the general population.

In order to evaluate the impact of our chemo-

prophylactic program on tuberculosis in Missis-
sippi, the annual new active case rate for the ten i
years before the institution of our program is
shown in figure 4.

During the years 1959, 1960, and 1961, the
rapid decline in new active cases was mainly due
to lack of reporting and poor case finding.

In 1963, our present control program was put
into effect and the number of new active cases
surged upward in 1964 as the previously unre-
ported cases were ferreted out of the county
health departments’ files and reported to the reg-
ister. During 1965 a readjustment took place and
the new active cases reported dropped from the
peak of 751 in 1964 to 661. Then in 1966 and
1967, a leveling off took place and the new active
cases fell only from 661 in 1965 to 654 in 1966,
a matter of 7 cases, and to 616 in 1967, a drop
of 38 cases.

Our chemoprophylactic program was put into
effect in November, 1967. The new active case
rate, in spite of careful attention to case finding
and reporting, dropped from 616 in 1967 to
558 in 1968, a fall of 58 cases. In 1969 new cases
numbered 457, a drop of 101 in new active cases.

Inasmuch as chemoprophylaxis is the only new
factor added to our routine in 1968 and 1969,
we feel that if the acceleration in the decline of
new active cases continues, it will have to be cred-
ited to chemoprophylaxis.

CONCLUSION

A review of the state tuberculosis register for
the last 12 years reveals that since our chemo-
prophylactic program was put into effect, there
has been a definite acceleration of rate of decline
in the new active cases reported to the register.

If this continues, it will indicate that chemopro-
phylaxis is one of the most important factors in
control of tuberculosis in Mississippi. We believe
that it warrants the attention and cooperation of
all physicians and medical facilities in the state.

★★★

2423 North State Street (39216)

REFERENCES

1 . American Thoracic Society, Chemoprophylaxis for the
Prevention of Tuberculosis; Statement by an Ad Hoc
Committee. Amer. Rev. Resp. Dis. 96:558-560, 1967.

2. Reid, L. R.: The Mississippi Program of Chemopro-
phylaxis for the Prevention of Tuberculosis, JMSMA
IX:325-327, 1968.

3. Ferebee, S. H.: Long Term Effects of Isoniazid Pro-
phylaxis. Bull. Int. Un. Tuber. 41:161-6 (Dec.) 1968.

4. U. S. Bureau of the Census, Statistical Abstract of
the United States: 1969 (90th edition), Washington,

D. C., 1969. p. 12.

5. National Communicable Disease Center, Tubercu-
losis Branch, Atlanta, Ga. (March) 1970.

492

JOURNAL MSMA

Seminar on Care of the Newborn— III

Acute Bacterial Infections in the Newborn

DENNIS I. WRIGHT, M.D., and
ALFRED W. BRANN, JR., M.D.

Jackson, Mississippi

Acute bacterial infections are a significant
primary or contributing cause of death and seri-
ous morbidity in the neonatal period. Yet, with
currently available therapeutic measures, most
bacterial infections are curable. The morbidity
and mortality from infections in the newborn have
decreased since the advent of antibiotics, but
this decrease has not been as dramatic for the
newborn as for other age groups. The peculiari-
ties of the neonate and his environment which
are relevant to the etiology, pathogenesis, and clini-
cal expression of infection are discussed here, in
an effort to aid the physician in suspecting and
diagnosing infection at the earliest possible mo-
ment. Emphasis is then placed on prompt initia-
tion of therapy particularly appropriate to the
neonate.

Numerous bacteria have been reported as etio-
logic agents in acute infections of the neonatal
period. However, published series on the five ma-
jor infectious processes in the neonate (sepsis,
meningitis, pneumonia, urinary tract infection,
and diarrhea) have shown the gram-negative or
enteric organisms to be the most frequent offend-
ers. In a recent review of several series1 extend-
ing from 1927 to 1968, gram-positive organisms,
predominantly beta hemolytic streptococcus,
were found to be the most frequent offender
prior to 1944. Since 1944, with one exception,2
the gram-negative organisms, predominantly
E. Coli, were found to be the most frequent
offenders. In that instance, the change from
gram-positive to gram-negative organisms did not
occur until after 1959. An explanation for this
is not readily apparent but the point to be empha-
sized is that the organisms associated with infec-
tions do vary from hospital to hospital.

From the Department of Pediatrics, University of Missis-
sippi School of Medicine.

It has been noted,1 that when cases of sepsis
are arranged according to age at onset, a division
at 72 hours reveals a definite grouping of the
etiologic agents. This grouping has definite thera-

Acute bacterial infections are a signi-
ficant primary or contributing cause of death
and serious morbidity in the neonatal period.
Currently available therapeutics, especially
the antibiotics, have rendered most bacterial
infections curable. The authors discuss the
various etiologic agents and suggest appro-
priate therapy.

peutic implications affecting the choice of anti-
biotic therapy to be instituted prior to the identi-
fication of the specific etiologic agent. Table I is
a listing of the most common pathogens in acute
bacterial infections before and after 72 hours of
age.

Diarrhea differs from the other major infections
of the newborn in regard to the etiologic agents
involved. Although many diarrheas in the new-
born period are of non-bacterial etiology, bac-
terial diarrheas do occur with significant fre-
quency. Pseudomonas and proteus have been
described as possible etiologic agents, in those in-
fants in whom an overgrowth of either of these
agents has occurred. Salmonella and Shigella oc-
casionally cause diarrhea in the newborn.

E. Coli is not usually considered a pathogen,
but there are known pathogenic strains of E. Coli
which have produced epidemic diarrhea in the
newborn. Stool cultures should be obtained in all
cases of diarrhea and the laboratory should be
requested to identify the predominant organisms.
A report of “no pathogens noted” is not sufficient.

SEPTEMBER 1970

493

NEWBORN INFECTIONS / Wright et al

If E. Coli predominates on culture, specific
typing should be done to identify possibly patho-
genic strains. If this service is not available local-
ly, it can be obtained from the Mississippi State
Board of Health.

The two basic factors in the pathogenesis of
infections in the newborn are: 1) the neonate’s
state of impaired host-resistance and 2) the pres-
ence of certain environmental factors predispos-
ing to infection.

The impaired host-resistance of the fetus and
neonate reflects the immature state of the diverse
systems which must participate in meeting a bac-
terial challenge. The first barrier to invasion, the
skin and mucous membranes, is usually adequate
unless an inoculum of bacteria is introduced
past the barrier through open wounds such as
the umbilical stump or unless the inoculum is
of such an amount as to overwhelm the system, as
in amniotic infection syndrome. Two factors im-
portant to clearing or localizing an infecting force
which has penetrated the surface barrier are the
inflammatory response and the phagocytosis of
foreign particles by leukocytes. Both these proc-
esses have been demonstrated to be impaired in
the newborn.3’ 4

Humoral factors are also important to host-
resistance. It is known that the human fetus can
respond to bacterial, viral, protozoal and spiro-
chaetal infections in utero by producing anti-
bodies, particularly those of the immunoglobu-
lin M (IgM) fraction.5 In the noninfected intra-
uterine environment, however, the fetus acquires
his usual complement of immunoglobulins solely
by placental transport from the mother,6 this

TABLE I

BACTERIAL AGENTS CAUSING INFECTION
IN THE NEONATAL PERIOD

Infection Prior to 72 Hours
of Age

Infection After 72 Hours
of Age

E. Coli

Pseudomonas

Klebsiella-Aerobactor

Proteus

Enterococcus

Klebsiella-Aerobactor

Beta Hemolytic

E. Coli

Streptococcus

Staphylococcus

Staphylococcus

being primarily those of the immunoglobulin G
(IgG) fraction. Since immunoglobulin M and im-
munoglobulin A are not transferred across the
placenta, the previously noninfected infant is de-
livered deficient in these factors. The antibodies

to gram-negative organisms are in the IgM frac-
tion, but the significance of this deficiency regard-
ing the increased occurrence of gram-negative
infections is not fully understood. It is interesting
to note that the only period of life during which
the human is subject to primary sepsis caused by
colon bacilli is the first two weeks of life.7

Another factor in acquiring immunity to spe-
cific infections is delayed hypersensitivity. Neo-
nates are known to develop delayed hypersensi-
tivity, but the rate of its development is much
slower than in older children and adults.8

ENVIRONMENTAL FACTORS

Table II is a list of prenatal and postnatal
environmental factors that are known to predis-
pose the infant to infection. Infants born to
mothers with infections, particularly infections of
the urinary tract, cervix, and vagina, are known
to have an increased incidence of infection.9’ 10
As much as a six-fold increase in the incidence
of infection among neonates born to mothers with
urinary tract infections at the time of delivery
has been documented.10 Even when a specific
locus of maternal infection cannot be identified,
an increased number of infected infants are born
to febrile mothers.11 Rupture of fetal membranes
greater than 24 hours prior to delivery has been
well documented as predisposing to the events
leading to infection in the neonate.12 One to 30
per cent of cases of amnionitis has been reported
to precede systemic infection in the newborn.13
The amniotic infection syndrome has been well
characterized by Blanc14 as related to prolonged
rupture of fetal membranes with ascending in-
fection.

Excessive manipulation of the fetus during
labor as well as excessive bleeding from placenta
previa or abruptio placenta have been associated
with an increased incidence of infections in the
neonate. The exact mechanism is unknown but an
increased opportunity for organisms in the vagina
to gain access to the placenta and the fetal circula-
tion is postulated. Infants having an episode of
fetal distress as indicated by either passage of
meconium or variations in fetal heart rate, have
been found to have an increased incidence of in-
fection.15 The unclean delivery, as a predisposing
factor to infection, is distinguished from the
“unsterile” delivery since an occasional infant
may be contaminated with maternal excreta under
the best precautions in the delivery room.

Postnatal environmental factors predisposing an
infant to infection are particularly revelant to
those infections with onset after 72 hours of age.
These circumstances may present the infant with

494

JOURNAL MSM A

an inoculum of organisms in such a manner or
in such an amount as to produce infection. A dif-
ficult resuscitation, particularly if requiring en-
dotracheal intubation or umbilical vessel cathe-
terization, offers many opportunities to introduce
organisms into a normally sterile area of the
child’s body. The danger of seeding and facilitat-
ing infection is further increased when foreign
bodies such as umbilical vessel catheters and
endotracheal tubes are left indwelling. The in-
creasing risk of systemic infection after 24 hours
of indwelling umbilical catheters may justify the
initiation of antibiotics. It is the authors’ practice
in such cases to initiate antibiotics as in suspected
sepsis.

Low birth weight infants, premature or small
for dates, have an increased incidence of infec-
tion probably related to an exaggerated immuno-
logic immaturity and to frequent association with
the environmental factors predisposing to infec-
tion both pre- and postnatally.15’ 16 Congenital
malformations most commonly predispose to in-
fection by providing a portal of entry as in leak-
ing meningiomyeloceles.

NURSERY SURVEILLANCE

Exposure to particularly pathogenic agents re-
sulting in infection is usually the result of inade-
quate nursery surveillance for these pathogens
and failure to adhere to methods designed to re-
duce their presence in the nursery to the lowest
possible level. Epidemics of sepsis have been re-
ported in nurseries using inappropriately cleaned
equipment, particularly suction equipment and
isolettes.16 Nursery personnel and nursing moth-
ers must not be overlooked as possible reservoirs
of pathogenic organisms. The single most impor-
tant measure in controlling intra-nursery spread
of infection is rigidly enforced hand washing by
all personnel before handling each infant.

The nonspecific symptomatic expression of
clinical illness in the neonate is the peculiarity of
this age group most frustrating to the physician
with infants in his charge. This is particularly
true for the subtle, early signs of systemic in-
fection. However, the alert, experienced nurse
who is frequently handling and feeding the child
will often, in the absence of obvious signs, develop
the impression that the infant is “not doing well.”
When this is brought to the attention of the physi-
cian, he is well equipped with a strong suspicion
of infection, especially when supported by a his-
tory of aspects of pregnancy, labor, delivery, or
clinical course predisposing to infection. Then
with careful review of the infant’s behavior and
feeding pattern and with careful physical exami-
nation including, most importantly, a period of

observation of the infant’s activity, one can usu-
ally itemize a few of the nonspecific but definite
changes which have occurred. The most fre-
quent of the early signs of systemic infection
are variations of activity — lethargy or irritability,

TABLE II

ENVIRONMENTAL FACTORS PREDISPOSING
TO INFECTION

Prenatal Factors Postnatal Factors

1. Maternal infections-
fever.

2. Prolonged rupture of
fetal membranes.

3. Amnionitis

4. Excessive bleeding
during labor.

5. Difficult delivery.

6. Unclean delivery.

7. Fetal distress.

1 . Difficult resuscitation.

2. Noninfectious illnesses.
Umbilical vessel cathe-
terization.

Surgical procedures.

3. Low birth weight.

4. Congenital malforma-
tions.

5. Exposure to particular-
ly pathogenic agents.
Improperly washed

hands of personnel
Improperly cleaned
equipment
Maternal or nurse
carrier.

variations in temperature — hypo- or hyperther-
mia, variations in feeding pattern — decreased in-
take and variations in respiratory pattern — res-
piratory distress or apnea.1’ 18 Table III provides
a list of the more common signs and symptoms
associated with systemic infection.

LACK OF SPECIFICITY

The lack of specificity of an infant’s symp-
tomatology must be re-emphasized. For example,
one must be aware of the broad differential
diagnosis which must be entertained when an in-
fant has a seizure. In addition to meningitis,
seizures may be the result of such noninfectious
etiologies as intracranial hemorrhage, anoxia, hy-
pocalcemia, hypoglycemia, and hyponatremia.
A similar differential diagnosis has to be made for
the many other signs and symptoms such as res-
piratory distress, jaundice, abdominal distention,
and petechiae which may be present in the infant
suspected of infection.

To aid the physician in distinguishing the in-
fected infant from the noninfected one, much ef-
fort has been invested in a search for useful lab-
oratory studies.

For the purpose of identifying the infant
infected at birth, various examinations of fetal
adenexa,19 umbilical cord,20 and gastric con-
tents21 for the presence of inflammatory cells

SEPTEMBER 1970

495

NEWBORN INFECTIONS / Wright et al

and bacteria have been employed. These tech-
niques, though sometimes helpful in a particular
case, have not been found routinely useful. Posi-
tive results occur with contaminated, though not
necessarily infected, infants and negative findings
are not infrequent with infants who become clini-
cally infected within 24 to 48 hours of birth. For
these reasons few centers employ these methods
routinely.

Determination of IgM levels in cord blood is
now being employed in some centers to detect
both acute and chronic infections of intrauterine
onset. This method, however, is of no aid in diag-
nosing infection of recent onset. The complex
subject of neonatal immunology including the use
of this method is exhaustively reviewed in part
II of the December, 1969 issue of the Journal of
Pediatrics.

Other laboratory parameters commonly used
to support a diagnosis of infection in other age
groups, particularly the white cell count and
differential, have not been found as useful for
the neonate. The white cell count must be beyond
the extreme of 25,000 WBC/mm3, or less than
4,000 WBC/mm3 to lend significant support to
a diagnosis of infection but the absence of these
extremes does not rule out the possibility of
infection. With the presence of a normal relative
neutrophilia up to 60 per cent of the total cell
count in the first 24 to 48 hours of life, the differ-
ential count loses its usefulness in reflecting in-
fection. Thrombocytopenia and evidence of he-
molysis without blood group incompatibilities are
occasionally associated with, but are not indicative
of, severe infections.1

TABLE III

SIGNS AND SYMPTOMS COMMONLY

ASSOCIATED WITH SYSTEMIC INFECTIONS
IN THE NEONATE

“Not doing well”

Poor Feeding
Hyper-or-Hypothermia
Lethargy or Irritability

Disturbances of respiratory pattern — respiratory distress
or apnea

Seizures — generalized or focal

Jaundice — with or without hepatosplenomegaly

Abdominal distention, vomiting or diarrhea

Urinalysis, particularly if obtained sterilely by
suprapubic bladder aspiration, is useful. Demon-
stration by gram stain or culture of any bacteria
in such a sterilely obtained specimen is indicative

of a urinary tract infection. In the sick infant,
it is suggestive of a systemic infection since the
urinary tract may be a site of disposal of bacteria
disseminated by the blood stream as well as a
portal of entry for bacterial infection. Micro-
scopic examination of a fresh uncentrifuged speci-
men obtained by bladder aspiration which reveals
more than two or three WBC’s per low power
field also supports a diagnosis of infection.1

EXAMINATION OF CSF

Examination of CSF is imperative in any sick
infant suspected of having systemic infection.
One third of the cases of neonatal sepsis are
complicated by menigitis1 and about two-thirds
of cases of meningitis are associated with sepsis.18
The diagnosis can be established immediately if
organisms are seen on gram stain of CSF. The
gram staining characteristics of the organism are
also of assistance in selecting the antibiotics to
be used. In the absence of organisms on smear,
the presence of meningitis can be inferred from a
cell count of greater than 10, particularly if poly-
morphonuclear cells predominate. A CSF glucose
of less than one-half the serum value also suggests
meningeal infection. An elevated CSF protein,
>125 mgm per cent, supports a diagnosis of
meningitis with other evidence, but is less specific
than the cell count and the glucose level.1- 18

Blood cultures, CSF and urine cultures are
keys to establishing a diagnosis and identifying
the etiologic agent. Routine cultures of cord,
skin, and throat at times yield helpful clues, but
have not been found reliable in demonstrating
the pathogen in sepsis.

PRESUMPTIVE DIAGNOSIS

With the definitive diagnosis of infection de-
pendent upon the results of cultures which may
not be available for several days following the
initial evaluation, it is apparent that one must
make a presumptive diagnosis on clinical judge-
ment if he is to initiate treatment early. One
must appreciate this uncertainty and accept the
fact that some infants will be treated unnecessari-
ly. Antibiotics properly selected and adminis-
tered in the proper dosage are of negligible risk
to the well child compared to the odds against
an infected infant who is not treated or for whom
treatment is delayed.

Management of acute bacterial infections be-
gins with a presumptive diagnosis. In most cases
the specific etiologic agent is unknown although
gram stains of CSF and urine may have given
valuable clues. Positive identification of the or-
ganism and determination of its specific anti-
biotic sensitivities requires time which the infec-

496

JOURNAL MSMA

TABLE IV

ANTIBIOTICS COMMONLY USED IN THE NEONATAL PERIOD

Antibiotic

Indications

Parenteral Dosage

Toxicity and
Comments

Intrathecal
Dosage/ lcc
Saline

Penicillin-G

Gram-positive infections or
presumptive sepsis before age
72 hours

100,000 u/kg/d
IM or IV q 12h

q 6-8 hr

—

Ampicillin

100 mg/kg/d
IM or IV q 12h

after age 5 days

—

Kanamycin

Nonpseudomonas gram-nega-
tive infection — with a peni-
cillin for presumptive sepsis

15 mg/kg/d
IM q 12h

Renal and auditory
toxicity rare in
infants

1 mgm.

Polymyxin-B

Known or suspected Pseudo-

4 mg/kg/d
IM q 12h

Alternate drug
for pathogenic
E. Coli

1 mgm.

Colistin

monas infection

8 mg/kg/d
IM q 12h

Not to be used

Methicillin

Penicillin resistant gram-
positive infection — pre-

200 mg/kg/d
IM q 12h

q 6-8 hr. after
age 5 days

—

Nafcillin

sumptive sepsis after age
72 hr.

200 mg/kg/d
IM q 12h

Nephrotoxic in
high doses

—

Neomycin

Bacterial diarrhea
Enteropathogenic E. Coli

50-100 mg/kg/d
P.O. q 4-6h

Not used
parenterally

Not used

ted infant can ill afford. Therapy must be initiated
immediately with antibiotics chosen from a con-
sideration of the most likely etiologic agents and
their sensitivities. In the choice of antibiotics
one must also recognize a need for thorough
coverage and the greatest possible effectiveness
because of the rapid progression of infection in
the neonate. One must be aware of the unique-
ness of antibiotic metabolism in the neonate which
makes proportionate reduction of the usual dose
schedules grossly inaccurate and makes the usual
considerations of toxicity inapplicable.

Based upon these considerations, it is our
practice and the practice of most centers to begin
therapy with kanamycin and either penicillin-G
or ampicillin when a presumptive diagnosis of
systemic infection is made within the first 72
hours of life. Kanamycin is important for its
broad coverage of E. Coli and Klebsiella-Aero-
bacter, most strains of Shigella and Salmonella,
and some strains of Proteus and Pseudomonas.
Though renal and auditory nerve toxicity are ob-
served relatively frequently in older children and
adults receiving kanamycin, these are rarely en-
countered in the infant. Much experience and
study has shown the recommended dose of 7.5
mg/kg given every 12 hours to be effective
and safe.22 Ampicillin is increasingly being cho-

sen over penicillin, in spite of its expense, for its
effectiveness agains Proteus mirabilis, H. influ-
enza, many strains of E. Coli and Salmonella and
some strains of Klebsiella-Aerobacter, as well as
the penicillin sensitive gram-positive cocci.

If onset of sepsis is suspected after 72 hours,
the possibility of a penicillin-ampicillin resistant
staphylococcus indicates the use of an agent to
which these are usually susceptible. Methicillin
appears to be the drug of choice and it is sub-
stituted for penicillin-ampicillin in the usual regi-
men. Nafcillin may also be used.

Pseudomonas must be considered with any
sepsis and particularly those with onset after 72
hours. Whenever pseudomonas is suspected, poly-
myxin-B or colistin should be included in the
initial antibiotics. If meningitis is present, poly-
myxin-B should be administered intrathecally
since neither polymyxin nor colistin cross into the
CSF in appreciable amounts. Colistin should nev-
er be used intrathecally.

With these few drugs, penicillin-ampicillin.
kanamycin, methicillin-nafcillin, and polymyxin-
B — colistin, one has the antibiotic armamentar-
ium necessary to treat almost all acute systemic
bacterial infections encountered in the nursery.
Rarely will culture and sensitivity studies indicate
the need for other antibiotics with which neonatal

SEPTEMBER 1970

497

NEWBORN INFECTIONS / Wright et al

experience is limited or increased risk of toxicity
is known. Antibiotics to be avoided in the new-
born period for these reasons include chloram-
phenicol, tetracycline, sulfonamides, linocmycin,
cephalothins, nitrofurantoins, novobiocin, nali-
dixic acid and gentamycin.22’ 23 Table IV pre-
sents indications and dosage schedules for anti-
biotics in the neonatal period.

Having begun an infant on an antibiotic regi-
men with a presumptive diagnosis of systemic in-
fection, the course is continued until culture and
sensitivity studies are complete or clinical deteri-
oration of the infant indicates a need for im-
mediate alternation of therapy. If a single orga-
nism is cultured and found sensitive to a single
antibiotic, then this antibiotic should be continued
alone. For example, if a Beta-hemolytic Strep-
tococcus sensitive to penicillin-G is cultured, then
penicillin should be continued alone for a full
ten-day course and kanamycin should be dis-
continued from the initial regimen.

If the organism is found sensitive to neither of
the initial antibiotics, then the least toxic alterna-
tive, to which the organism can be demonstrated
to be sensitive, should be substituted and the
original antibiotics discontinued. If no organism is
demonstrated on cultures and the clinical course
is one of improvement, it is our policy to continue
the initial antibiotics for a full course. Some cen-
ters, however, discontinue antibiotics after three
days and then repeat cultures after another 24
hours of observation. If the infant is clinically
deteriorating, the cultures are repeated and poly-
myxin-B is substituted for kanamycin to cover
the possibility of Pseudomonas or resistant E. Coli
as the infecting organism.

DIAGNOSTIC STUDIES

While awaiting cultures, with the infant begun
on therapy, one should continue diagnostic studies
to demonstrate the primary focus of infection and
to rule out noninfectious disease processes. With
the completion of these studies and the reporting
of positive cultures, the extent of the infection
can be more clearly defined as sepsis, meningitis,
pneumonia, urinary tract infection or a combina-
tion of these, and the therapeutic plan can then
be widened to include any special considerations
relevant to these specific entities as will be dis-
cussed.

With the presumptive diagnosis of systemic
infection, sepsis is assumed. A definitive diagnosis
is made with a positive blood culture in a symp-
tomatic patient. If the physician is appropriately
aggressive in his approach to infection, sepsis will

not infrequently be suspected and treated, but
because of negative blood cultures will remain
unproven. This is particularly true of such cases
as aspiration syndromes which may be treated on
the basis of high risk prior to the onset of symp-
toms.

Antibiotics as initiated or as altered on the basis
of culture and sensitivity should be continued
parenterally for seven to ten days depending on
the clinical response. Follow-up cultures are im-
portant in evaluating the effectiveness of therapy.

Antibiotic therapy should be supplemented with
appropriate supportive measures. The most im-
portant of these is attentive nursing care and ob-
servation. If the infant is feeding poorly or the
severity of his symptoms indicate the possibility
of aspiration, appropriate fluids, calories, and
electrolytes should be administered intravenously
until significant clinical improvement occurs. Ade-
quate pulmonary ventilation must be maintained.
The airway should be cleared by suction as often
as necessary. Periods of apnea should be antici-
pated and watched for; electronic monitoring is
useful but does not substitute for the attentive
nurse. Artificial ventilation may be intermittently
necessary if periods of severe apnea associated
with bradycardia occur.

OXYGEN ADMINISTRATION

Oxygen should be administered only as re-
quired to maintain adequate oxygenation. When
oxygen is used, the concentration in the inspired
air should be monitored hourly and the blood
gases followed to prevent hyperoxygenation. The
rectal temperature should be monitored and main-
tained within the limits of 97 to 99 °F. The warm
environment of an incubator is usually sufficient
if an isolette is not available. Either of these
closed environments also provides adequate iso-
lation if strict hand washing to the elbows before
and after each handling of the infant is observed
by all personnel. Hyperthermia (a rectal tem-
perature >103°F) should be managed with tap
water sponges. Antipyretics are rarely, if ever,
necessary.

OTHER COMPLICATIONS

Less common complications, but ones for which
the physician must be alert, are endotoxic shock,
intravascular coagulation, and inappropriate anti-
diuretic hormone secretion resulting in hypona-
tremia.1 The possibility of concomitant or super-
imposed infections by organisms resistant to the
antibiotics in use must be kept in mind as well as
the possibility of drug toxicity.

Meningitis must be ruled out whenever sys-
temic infection is suspected. The early signs are

498

JOURNAL MSMA

indistinguishable from those of any serious infec-
tion. The classical signs, bulging fontanelle and
stiff neck, are not reliably present.18 With an
atraumatic lumbar puncture the diagnosis can
usually be established immediately by the studies
previously discussed. If a traumatic tap is ob-
tained this fluid should be cultured but the pro-
cedure should be repeated in 12 to 24 hours in
an attempt to obtain fluid satisfactory for study
even though antibiotics have already been initi-
ated. The diagnosis of meningitis, if present, is
imperative since intrathecal administration of an-
tibiotics may be necessary for effective treatment.

If the diagnosis of meningitis is made with the
initial lumbar puncture, therapy should be initi-
ated as with sepsis. If the infant is very ill and
numerous organisms are seen on smear, intra-
thecal administration of antibiotics should be ini-
tiated also. Penicillin-G or ampicillin should be
used for gram-positive organisms unless penicillin
resistance is suspected in which case methicillin
may be used. Kanamycin would be the drug of
choice for gram-negative organisms unless Pseu-
domonas is suspected. When Pseudomonas men-
ingitis is suspected, then, regardless of the clinical
condition of the patient, intrathecal administra-
tion of polymyxin-B must begin immediately since
parenterally administered polymyxins, including
colistin, do not enter into the CSF in appreciable
amounts. Colistin should never be given intra-
thecally.22’ 24

INTRATHECAL ADMINISTRATION

Whether or not intrathecal antibiotics are in-
cluded in the initial treatment, a repeat lumbar
puncture should be performed after 24 to 36
hours of therapy. If organisms are present on
smear at this time, intrathecal antibiotics are indi-
cated. If the clinical response has been poor, the
possibility of Pseudomonas meningitis must be
covered by the initiation of polymyxin-B intrathe-
cally and parenterally.23 The dosage for intra-
thecal administration is given for each of the
drugs in Table IV.

One should be certain of good needle position
and free flow of spinal fluid before injecting anti-
biotics intrathecally. The drug must be diluted
either with saline or with CSF prior to injection.
It is judicious to drain off at least an equal volume
of CSF prior to injection of a drug containing
solution. The usual schedule of intrathecal therapy
is to give daily injections for three days then
every-other-day until the CSF has been found
clear on three successive occasions. Parenteral
antibiotics are continued for one week after the
infant is afebrile and the spinal fluid is clear.

If in the course of treatment, there is continuing

fever and slow clinical response in spite of pro-
gressive clearing of the CSF on serial study, sub-
dural taps are indicated, particularly if focal neu-
rological signs or increasing head circumference
are evident. If subdural effusions are found, serial
taps should be performed until these are dry. If
hydrocephalus develops, a neurosurgeon should
be consulted to assist in exploring the possibility
of ventriculitis with obstruction.

Bacterial pneumonia is a relatively common
infection in the neonate. It may occur as a pri-
mary infection, as a secondary infection with sep-
ticemia, or as a superimposed infection with as-
piration syndrome, hyaline membrane disease or
other noninfectious respiratory diseases. When
the diagnosis is suspected, it should be supported
by chest x-ray and the indentification of the etio-
logic agent should be attempted with cultures of
blood, tracheal aspirate, and pleural fluid, if ob-
tainable. Cultures of the upper airway serve only
to confuse the clinician. Antibiotic therapy and
supportive measures should be instituted as with
a sepsis with particular attention applied to
maintenance of adequate ventilation and oxygena-
tion.

URINARY TRACT INFECTION

In an infant with symptoms of a systemic in-
fection, bacterial growth from sterilely obtained
urine may reflect either a primary urinary tract
infection, or urinary deposition of blood-borne
organisms. This distinction does not affect initial
therapy since treatment for sepsis would be initi-
ated in either case. However, a positive urine cul-
ture does present the need for further diagnostic
studies. An intravenous pyelogram and cinecys-
togram should be obtained to rule out urinary
tract anomalies and urine cultures should be ob-
tained on follow up to rule out chronic urinary
tract infection.

NEWBORN DIARRHEA

The management of acute bacterial diarrheas
in the newborn is not based upon the treatment
of septicemia as is the treatment of meningitis,
pneumonia, and urinary tract infections. Though
diarrhea may be associated with sepsis, it most often
presents as an isolated entity. When bacterial
diarrhea is suspected, neomycin is the initial drug
of choice. The usual dosage is 50 to 100 mgm/
kgm/day given orally. A five-day course is usually
sufficient to clear the Gl-tract of pathogenic E.
Coli, the most common cause of bacterial diarrhea.
Rarely will cultures indicate a need to change
antibiotics. In those instances of pathogenic E.
Coli resistant to neomycin, polymyxin-B 20 mgm/
kgm/day p.o. is usually effective. As exceptions,

SEPTEMBER 1970

499

NEWBORN INFECTIONS / Wright et al

Shigella and Salmonella are best treated with
ampicillin. Parenteral antibiotics are indicated
only with systemic symptoms suggesting sepsis.

With diarrhea, antibiotic therapy is only a small
part of the total management. Mortality and se-
vere morbidity are almost always a consequence
of major fluid and electrolyte imbalances. There-
fore, when dealing with an acute diarrhea, par-
ticularly in an infant, one’s emphasis in manage-
ment must be on maintenance of fluid and elec-
trolyte balance.

The isolette or incubator does not afford ade-
quate isolation for acute diarrheas. Their epidemic
nature makes it imperative that infected infants
be isolated on a separate ward with the attending
personnel having minimal, if any, contact with
unaffected infants.

In conclusion, the authors would like to em-
phasize the importance of the nurse’s role in
identifying the infant who is not doing well so
that diagnosis and treatment may precede the
development of severe morbidity. Their diligent
attention to every infant, for all are at some de-
gree of risk, is to be greatly encouraged. ***

2500 N. State Street (39216)

REFERENCES

1. GotofF, S. P., and Behrman, R. E.: Neonatal Septice-
mia, J. Ped. 76:142, 1970.

2. McCracken, G. H., and Shienefield, H. R.: Changes
in the Pattern of Neonatal Septicemia and Menin-
gitis, Amer. J. Dis. Child 112:33, 1966.

3. Seto, D. S. Y., and Drachman, R. H.: Response to
Bacterial Infection in the Mature and Immature Ani-
mal (Abst.), J. Pediat. 69:978, 1966.

4. Miller, M. E.: Phagocytosis in the Newborn Infant:
Humoral and Cellular Factors, J. Pediat. 74:255,
1969.

5. Alford, C. A., Schaefer, J., Blakenship, W. J., Straum-
ford, T. V., and Cassady, G.: A Correlative Im-
munologic, Microbiologic, and Clinical Approach to
the Diagnosis of Acute and Chronic Infections in
Newborn Infants, New Eng. J. Med. 277:438, 1967.

6. Vahlquist, B.: The Transfer of Antibodies From
Mother to Offspring, Adv. Pediat. 10:305, 1958.

7. Janeway, C. A.: The Immunological System of the
Child. Part 1: Development of Immunity in the
Child, Arch. Dis. Childh. 41:358, 1966.

8. Uhr, J. W., Davis, T., and Newmann, C. G.: De-
layed-Type Hypersensitivity in Premature Neonatal
Humans, Nature 187:1130, 1960.

9. Keitel, H. G., Hannanian, J., Ting, R., Prince, L. N.,
and Randall, E.: Meningitis in the Newborn Infant,
J. Pediat. 61:39, 1962.

10. Zilliacus, H., and Totterman, L. E. : Raised Inci-
dence of Infection in Infants Born to Mothers With
Infections of the Urinary Tract at the Time of De-
livery, Gynaecologia 135:353, 1953.

1 1. Smith, J. A. M., Jennison, R. F., and Langley, F. A.:
Perinatal Infection and Perinatal Death, Clinical As-
pects, Lancet 3:903, 1956.

12. Pryles, C. V., Steg, N. D., Nair, S., Gellis, S. S.,
and Tenney, B.: A Controlled Study of the Influence
on the Newborn of Prolonged Rupture of the Amni-
otic Membranes and/or Infection in the Mother,
Pediatrics 3 1 :608, 1963.

13. Blane, W. A.: Pathways of Fetal and Early Neonatal
Infection, J. Pediat. 59:473, 1961.

14. Blane, W. A.: Amniotic Infection Syndrome. Path-
ogenesis, Morphology, and Significance in Circum-
natal Mortality, Clin. Obstet. Gynec. 2:705, 1959.

15. Overall, J. C. : Neonatal Bacterial Meningitis. J.
Pediat. 76:499, 1970.

16. Kagan, B. M., Hess, J. H., Mirman, G., and Lun-
deen, E. : Meningitis in Premature Infants, Pediatrics
4:479, 1949.

17. Hoffman, M. A., and Finberg, L. : Pseudomonas In-
fections in Infants Associated With High-Humidity
Environments, J. Pediat. 46:626, 1955.

18. Overall, J. C.: Neonatal Bacterial Meningitis, J.
Pediat. 76:499, 1970.

19. Kelsall, G. R., Barter, R. A., and Manesis, C.: Pro-
spection Bacteriological Studies in Inflammation of
the Placenta, Cord and Membranes, J. Obstet. Gynec.
Brit. Comm. 74:401, 1967.

20. Overbach, A. M., Daniel, S. J., and Cassady, G.:
The Value of Umbilical Cord Histology in the Man-
agement of Potential Perinatal Infections, J. Pediat.
76:22, 1970.

21. Blanc, W. A.: Amniotic Infection Syndrome. Patho-
genesis, Morphology, and Significance in Circumna-
tal Mortality, Clin. Obstet. Gynec. 2:705, 1959.

22. McCracken, G. H., Jr., Eichenwald, H. F., and Nel-
son, J. D.: Antimicrobial Therapy in Theory and
Practice. II. Clinical Approach to Antimicrobial Ther-
apy, J. of Pediat. 75:923, 1969.

23. Eichenwald, H.: Antibiotics and the Newborn, Hos-
pital Practice 2: 1967.

24. McCracken, G. H., Jr., Eichenwald, H. F., and Nel-
son, J. D.: Antimicrobial Therapy in Theory and
Practice. I. Clinical Pharmacology, J. of Pediat. 75:
742, 1969.

EQUINE EQUANIMITY

“Last week,” said the trainer of questionable sportsmanship,
“I gave my horse a big shot of amphetamine and a grain of mor-
phine just before the big handicap.”

“Gosh,” replied his companion. “Did he win?”

“No,” sighed the trainer, “but he was the happiest horse in the
race.”

500

JOURNAL MSMA

Counsel to Authors

The Journal welcomes manuscripts
which should be submitted to the Editors
at 735 Riverside Drive, Jackson, Miss.
39216, in original and at least one dupli-
cate copy. They must be typewritten dou-
bled spaced on 8V2 by 11-inch white bond
paper with a standard typewriter.

The author is responsible for all state-
ments made in his work, including changes
made by the manuscript editor. Manuscripts
are received with the understanding that
they are not under simultaneous considera-
tion by any other publication and have not
been previously published. All manuscripts
will be acknowledged, and while those re-
jected are generally returned to the author,
the Journal is not responsible in event of
loss. Manuscripts accepted for publication
become the property of the Journal and
are copyrighted by the association when
published. They may not be published else-
where without written release and permis-
sion from both the Journal and the author.

All copy must be double spaced, in-
cluding legends, footnotes, and references.
Generous margins at the top, bottom, and
on both sides of the page should be allowed.
Each page after the title page should be
consecutively numbered and carry a run-
ning head identifying the paper and author.

Titles should be short, specific, and clear.
Ordinarily, a title should not exceed 80
characters, including punctuation.

References should be limited to a maxi-
mum of 10, but when justified to the Edi-
tors, additional references will be considered
for publication. Each will be critically ex-
amined, and only valid, primary references
will be published. Textbooks, personal com-
munications, and unpublished data may
not be cited as references. References must
include names of authors, complete title
cited, name of journal or book spelled out
or abbreviated according to the Index Med-
icus, volume number, first and last page
numbers, month, date (if published more
frequently than monthly), and year. Refer-

ences should be arranged according to order
listed in the text and must be numbered con-
secutively.

Manuscripts accepted for publication are
subject to copy editing. Authors will re-
ceive galley proof prior to publication. Gal-
ley proof is only for correction of errors,
and text changes may not be made. The
galley proof should be returned by the au-
thor within 48 hours from receipt, and no
further changes may be made after proof
sheets are received by the Journal.

Illustrations consist of all material which
cannot be set into type such as photographs,
line drawings, graphs, charts, and tracings.
Illustrations should be submitted separately
from text copy. Figures and drawings should
be professionally prepared with black ink
on white paper. Photographs should be of
high resolution, unmounted, untrimmed,
glossy prints. Each must be clearly identi-
fied. No charges are made to authors for
illustration engravings not exceeding four
column inches per printed page.

Illustrations must be numbered and cited
in the text. Legends, not exceeding 40
words and preferably shorter, must accom-
pany each illustration, typed double spaced
on separate sheets. The following informa-
tion should appear on a gummed label af-
fixed to the back of each illustration: Figure
number, manuscript title, author's name,
and arrow indicating top of the illustration.

In photographs in which there is any
possibility of personal identification, an ac-
ceptable legal release must accompany the
material.

A thesis summary of 75 to 100 words
must accompany each manuscript separately
from the text.

Reprints may be obtained at cost plus
shipping charges from the association and
should be ordered prior to publication. The
Journal reserves the right to decline any
manuscript. Authors should avoid placing
subheads in the text, and the Editors re-
serve the prerogative of writing and insert-
ing subheads according to Journal style.
— The Editors.

SEPTEMBER 1970

501

Radiologic Seminar XCIX

Endometriosis: An Unusual Cause of

Colon Obstruction

WALTER T. COLBERT, M.D.

Natchez, Mississippi

An admittedly rare cause of large bowel ob-
struction is involvement of the colon, usually
the sigmoid, by endometrial implants. An oc-
casional instance will be seen where differential
diagnosis from carcinoma of the large bowel can-
not be made pre-operatively. In other instances,

Sponsored by the Mississippi Radiological Society.
From the Department of Radiology, Jefferson Davis
Memorial Hospital.

the clinicial pattern and roentgenologic picture sug-
gest some sort of benign process producing partial
or complete colon obstruction, but again, a defi-
nite diagnosis cannot be rendered pre-operatively.
Just such a patient was encountered at our in-
stitution recently. Her case report appears below.

Case Report — Mrs. CM, 45 year old white
female, presented with a chief complaint of gen-
eralized abdominal cramping, principally in the
mid and lower abdomen, and increasing consti-

Figure 1. Barium enema examination demonstrat-
ing a smooth “ compression ” of the descending colon
just at the iliac crest.

Figure 2. Lateral view of sigmoid and descend-
ing colon demonstrating the same defect.

5 02

JOURNAL MSM A

pation. There had been no rectal bleeding, or
other symptoms related to the gastrointestinal
tract at the time of admission. A significant item
in the past history was noted, the patient having
had abdominal hysterectomy and right salpingo-
oophorectomy some ten years earlier, for benign
disease. At the time of the previous surgical pro-
cedure, no evidence of endometriosis was ap-
parent.

Plain films of the abdomen made on admission
demonstrated changes interpreted as representing
distal descending or sigmoid colon obstruction,
with considerable retention of fecal material
proximal to the site of suspected obstruction. Mul-
tiple cleansing enemata were administered, and
barium enema examination was carried out.

A rather definite, but somewhat atypical con-
strictive lesion was noted in the upper sigmoid
(figures 1, 2 and 3), but a definite diagnosis
could not be rendered. It was noted that the
mucosal pattern in this area was well preserved,
and it was felt that a malignant colon lesion
was unlikely.

At operation, the left fallopian tube and ovary
were involved in an extensive endometriosis, with
multiple adhesions in the left pelvis. The endome-
trial mass had produced partial obstruction of
the colon at the level noted on the films. It did
not appear to the operating surgeon that the endo-
metriosis had actually penetrated the bowel wall,
and bowel resection was not deemed necessary.
The patient recovered uneventfully.

In summary, a rather unusual instance of par-
tial distal colon obstruction on the basis of en-
dometriosis has been presented. The lesion in

Figure 3. Spot films of the descending colon area
in question demonstrating the smooth appearance in
the area of constriction , with apparent preservation
of mucosal pattern.

question is relatively rare, but must be considered
in the differential diagnosis of colon obstruction
in the female, particularly those patients in the
younger age groups. Complete recovery followed
surgical excision of the endometriosis in this in-
stance.

Sergeant E. Prentiss Drive (39120)

REFERENCES

1. Paul, Lester W., and Juhl, John H.: The Essentials
of Roentgen Interpretation, ed. 2. New York and Lon-
don: Harper and Row, 1965, p. 480-481.

2. Meschan, Isadore: Roentgen Signs in Clinical Prac-
tice. Philadelphia and London: W. B. Saunders Com-
pany. 1966. p. 1736-1737.

HIGH STAKES

A generous tipper at a summer resort found a new waiter serv-
ing him one morning and asked, “Say, where's Pete, my regular
waiter?” The new waiter smiled, “Sorry, sir, Pete won’t be serving
you anymore. I won you in a crap game last night."

503

SEPTEMBER 1970

Fifty-One Years in the Art:
A Family Physician Remembers

Modern medicine has lost much of the “art”
of diagnosis used in the past says an 81 -year-
old general practitioner from Calhoun City,
Dr. W. J. Aycock, who won the 1970 MSMA-
Robins Award.

The award for outstanding community service
by a physician was presented to Dr. Aycock at
the 102nd Annual Session at Biloxi by President
James L. Royals of Jackson and Mr. Williard
Duvall of New Orleans, district manager for
A. H. Robins Company of Richmond, Va.

Dr. Van B. Philpot, Jr., of Houston, Miss.,
whose father was a colleague of Dr. Aycock’s,
interviewed the veteran physician about his life
of medical service and changes in the practice of
medicine he has witnessed.

Dr. Aycock graduated from Memphis Hos-
pital Medical College in May of 1912, passed
the State Board examination, and set up practice
at Bentley, Miss.

Dr. W. J. Aycock of Calhoun City displays the
plaque he received as 1970 winner of the MSMA-
Robins Award for outstanding community service
by a physician.

He soon joined in partnership with Dr. B. C.
Tubb at Smithville and spent four years

A JOURNAL SPECIAL FEATURE

“doctoring” by horse and buggy in Monroe Coun-
ty. They delivered babies, treated pneumonia,
malaria, typhoid fever, measles and other infec-
tious diseases.

Dr. Aycock was interviewed by Dr. Van
B. Philpot, Jr., of Houston. Dr. Philpofs
father and Dr. Aycock were classmates and
long-time friends. The veteran physician has
many lively comments on medicine as it was
and is practiced.

Dr. Aycock moved back to Calhoun County,
but in July, 1917, practice was interrupted when
he departed for World War I. He served as a
First Lieutenant in the Army Medical Corps
until the end of the war.

After the war, he took postgraduate training
at the New York Postgraduate School and Tulane
University School of Medicine. He returned to
Mississippi, married and located at Derma, Wi
miles from Calhoun City, where he lives now.
The year was 1919 and there were no paved
roads so that the few Model T cars could only
operate in dry weather. The doctor still made
house calls by horse and buggy.

“One of the biggest improvements or boosts
to the practice of medicine has been the build-
ing of modern roads,” said Dr. Aycock. People
can now get out and go to the hospital when
they’re sick and get medical attention in much
less time, he pointed out.

Dr. Aycock especially appreciates the devel-
opment of antibiotics, improved surgical tech-
niques and the use of x-ray, but he adds that
some of the old ways ought to be retained to suc-
cessfully blend the art and science of medicine.

“We were taught to make our examination
from what we could see and hear and what the
patient told us and what we could feel. We were
supposed to use our common sense and medical

504

JOURNAL MSM A

training to put it all together to make a diagnosis,”
said Dr. Aycock.

The veteran physician estimated that he has
delivered about three thousand babies, mostly
in the patients’ homes with only a friend or rela-
tive to assist. Despite the harsh conditions, Dr.
Aycock said that he had only a few patients to
expire and fever was uncommon. This was be-
fore the time of blood banks, too. so there were
no transfusions.

Money was scarce and pay for services often
consisted of a pig, a few bushels of corn or a
yearling, remembers the doctor.

Dr. Aycock recalled the treatment for pneu-
monia when he was in the army; “Every day or
two the doctor gave pneumonia antigen to every
suspected case of pneumonia. The patients did
so well that I used the antigen on all my patients
when I got out of the army. I think it cut the
length of the disease down to about nine days
and the crisis to about six. It was a serum and
I gave it until antibiotics were discovered,” he
says.

“I was taught that when a patient had pain
in the abdomen, vomiting, tenderness that bor-
dered the ribs on the right side and especially
if he had jaundice, he had gall stones. This
worked every time for me.

“Now they can't find all the gall stones, and
don't operate just because one has those symp-
toms because I had them in 1967.

“I was hospitalized for jaundice and they
couldn't find gall stones. After nine days I began
to cramp a little, and they thought I had hepa-
titis.

"A few months later, I was jaundiced again
and had the same symptoms. They decided I
had cancer of the liver and did exploratory sur-
gery and found five big gall stones. So I think
if they’d use both the old and the new methods,
they'd be in better shape,” said Dr. Aycock.

Dr. Aycock was born in Phoeba in Oktibbeha
County, and attended schools in Bentley and Cal-
houn City. He got his premedical training at
Mississippi College in 1906 and went to medical
school in 1908. He sold a team of oxen, four
to the yoke, to help pay his way through medical
school.

He has practiced medicine in Calhoun City
for 51 years. He received his coveted 50-year
service pin and certificate in 1962 in special
ceremonies at the First Baptist Church of Cal-
houn City.

He has served his community through many
channels including: chairman of the Board of
Trustees of the Calhoun County Agricultural
High School at Derma, 1923-34; chairman of the
Calhoun City Special Consolidated School Dis-
trict, 1935-47; charter member of the Rotary
Club and served as president 1940-41; 20-year
member of Rotary Committee of the Hospital
for Crippled Adults of Memphis; member of the
Board of Deacons of First Baptist Church for
over 20 years; 32nd degree Mason and Shriner;
and member of the American Fegion Post No. 50.

Dr. Aycock has twice been president of the
Northeast Mississippi Medical Society and is an
emeritus member of MSMA and a member of
AMA.

QUESTIONABLE COMPLIMENT

A well-known violinist and his wife (also his accompanist)
were whisked off by the hostess to meet the guest of honor. “Mr.
Clay, I’d like you to meet Verdinni, the famous violinist. And
this is Mrs. Verdinni who has quite a reputation, too!"

SEPTEMBER 1970

505

The President Speaking

PAUL B. BRUMBY, M.D.
Lexington, Mississippi

‘Dilemma in Blue’

The basic problems of our relationship with the Mississippi Hos-
pital and Medical Service have defied solution for almost 10
years. This organization is now the fiscal agent for Part A of
Medicare and for the entire Medicaid Program. With this clearly
in mind, I was grateful for an invitation to the Coast meeting of
their board.

Their executives were certainly cordial and competent. The
Mississippi Hospital Association administrators were outstanding
and certainly were coping with their problems of hospital admin-
istration which let them speak with a common and effective voice.

The 10 public members are leaders in our state, well known
for their effective and selfless contributions to civic and philan-
thropic causes. So true is this, that I am told four members are
trustees of their local hospitals. The hospital trustees with their
employees, the administrators, naturally should be hospital-orient-
ed. But this hardly strikes a fair balance in a board which is self-
perpetuating. There is little chance for achieving change in direc-
tion as long as this condition exists.

In 1968 after years of discussion and consultation, our House
of Delegates withdrew our support from the Blue Shield Plan, but
did agree for one year to explore other avenues and approaches
to the inequity of this organization. The National Blue Cross-Blue
Shield Board recommended six changes in their operations. The
heart of these changes was the establishment of individual cor-
porations for each and for each to stand on its own bottom with
separate boards, and without intermingling of funds. Although
this was done in a number of states successfully, it was refused
here.

The MHMS board as then constituted reappointed the mem-
bers of MSMA who were previously on their board. But they are
there as individuals and not as a part of the structure of MSMA.
These are outstanding members of our association who work tire-
lessly in our behalf and they wish for better direction in a consul-
tative manner from MSMA. But it is hard to predict a permanent
settlement when pay for hospital-based physicians is twice that
of independent practitioners and the percentage of payout of Blue
Shield is questioned.

The physicians whose enthusiastic support has built these or-
ganizations are the only contact the subscriber has with the Blue
plans and it is getting increasingly difficult to explain the small
payment from this source. Not many of us are happy awaiting the
coming of National Health Insurance to make these problems
mute. ***

506

JOURNAL MSMA

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 9
SEPTEMBER 1970

The College and Cancer:
Saga of Enlightened Leadership

I

Cancer is the number two killer of all age groups,
and we may not be doing enough about it. The
assertion may seem drastic, what with the out-
pouring of hundreds of millions in ongoing pro-
grams of research, maintenance of specialized
institutions, a range of fellowships, and the work
of one of the three most important and influential
voluntary health organizations, the American
Cancer Society.

But with only 890 approved cancer programs
in the nation's 7,000-odd community and govern-
mental hospitals, the challenge is clear. Of course,
this doesn’t mean that adequate care for the dis-
ease is available only where an approved pro-
gram exists, but it’s odds-on that the patient is
better served when the professional resources and
medical facilities are marshalled together with
carefully defined objectives and stated goals.

The recommended cancer program of the
American College of Surgeons is such a coordi-
nated endeavor. It is conducted as a team effort
in concert with the American Cancer Society and
the Regional Medical Programs. Requirements
for approval of a local cancer program are set
out in the College's Manual for Cancer Pro-
grams. A special commission of the College over-

sees the entire undertaking, while individual Fel-
lows at regional and state levels voluntarily devote
time to leadership and coordination of local pro-
grams.

But one out of eight hospitals with an approved
cancer program seems hardly enough.

II

It is not altogether a question of size and af-
fluence as to the matter of a successful, approved
cancer program. The College says that its Com-
mission on Cancer “recognizes that both the
physical facilities and the number of trained per-
sonnel available for the care of cancer patients
vary widely among hospitals. However, the best
facilities and well-trained personnel do not in
themselves assure proper care of the patient with
cancer if they are not fully used for their intended
purpose.”

And this is the clincher: “Small hospitals whose
facilities are limited but whose personnel are well-
trained and aware of their limitations frequently
provide excellent care to the cancer patient. . . .”

The College bases its requirements for pro-
gram approval upon a number of accepted pre-
cepts:

— Cancer belongs in that unique category of
diseases which require, for the best care, that the

SEPTEMBER 1970

5 07

EDITORIALS / Continued

patient receive lifetime interval follow-through
examination. This will vary, the College says, de-
pending upon many factors, including age of the
patient, site of the cancer, stage of the disease,
and like considerations.

— Rapid advances in knowledge have led to
new modalities of diagnosis and treatment, vary-
ing with the site of the disease and involvement
in the care of different medical disciplines. The
College believes that the patient treated with a
multidisciplinary approach is likely to receive
most benefit.

— No longer can we be concerned only with
definitive treatment. Cancer must be considered
as involving three broad areas: Early diagnosis,
definitive treatment, and lifetime interval follow-
through examination. Neglect of any of these
areas, the College declares, is to be deplored.

Ill

The American College of Surgeons’ Commis-
sion on Cancer has adopted guides for effective
implementation of program requirements. Any
program must begin with organization of a hospi-
tal cancer committee as a standing body. The
multidisciplinary approach is emphasized in the
committee membership which should include rep-
resentatives of pathology, internal medicine, radi-
ology, gynecology, pediatrics, family practice, sur-
gery, and others as available.

A member of the committee should be re-
sponsible for maintenance of the registry. Sup-
porting the requirement for this facet of the pro-
gram, the College points out that lifetime follow-
through is important in many disease entities,
such as diabetes, rheumatic fever, heart disease,
and certain collagen diseases.

Frequently, the question of why not a central —
instead of a local — registry is raised. The guides
state that the hospital-based registry has the pri-
mary function of service to the patient by assur-
ing that he is followed and returned for examina-
tion. The secondary functions of incidence, trends,
comparative results of therapy, and the like may
not be available for an extended period of time,
and depending on the interval, these results may
or may not help those patients who have cancer
now. In the past, central registries have empha-
sized these secondary functions. The hospital reg-
istry is the most valuable input source for central
registries, but the College argues that this does
not relieve the hospital of maintaining its own
registry.

The proliferation of data processing hardware

or computers holds out great promise for tumor
registries. The state of Mississippi has given legal
protection to these service entities by furnishing
a liability shield. In past years where medicolegal
aspects demanded maintenance of patient ano-
nymity, the same patient biopsied at three different
clinics might show up as three different patients
and not just one. The resulting distortion of the
data is obvious.

IV

In a recent announcement, the College shows
seven approved cancer programs in Mississippi
hospitals. At Biloxi, there are ACS-approved pro-
grams in the Howard Memorial Hospital and the
USAF Hospital at Keesler Air Force Base. The
South Mississippi Tumor Clinic is conducted in
the Memorial Hospital at Gulfport, and an ap-
proved program has been established at the For-
rest County General Hospital at Hattiesburg.

Both the University Hospital and Veterans Ad-
ministration Center at Jackson have programs,
and one is conducted at Mercy Hospital-Street
Memorial in Vicksburg.

Much encouraging activity has been initiated
in Mississippi recently. A new program for detec-
tion of pelvic cancer has the support of the Missis-
sippi Regional Medical Program, a result of adop-
tion of a resolution at the 1969 Annual Session
of the state medical association. Quick passage
in the legislature of the liability shield for regis-
tries gave evidence of the growing public aware-
ness of the importance of these service activities.

508

JOURNAL MSM A

The pap smear program of the American Acad-
emy of General Practice has been greeted with
success.

If we have not done enough in the past with
the resources at our disposal, there is reason for
optimism today with a forward thrust on many
fronts. The efficient application of skills and re-
sources already available may be as important
as work in the research laboratory. In the mean-
while, the American College of Surgeons merits
our support and is to be commended and thanked
for its continued exercise of leadership in this
vital field of patient care. — R.B.K.

Rx for Inflation
and Drug Costs

A story is making the rounds about two men
discussing a television address by President Nix-
on. One said, “Did you hear the President speak
last night and what did you think of what he
said?”

“I heard him,” said the second man, “but I
can't discuss the speech. You see, our TV set
went on the blink before Eric Sevareid interpreted
and explained what he said.”

Of all the interpretation going on in this era
of analysis and comment, none is more plentiful
than that on the cost of medical care. Physicians
come in for a lion’s share of talk, usually on
the mounting medical service component. The fact
that M.D.’s have received only 11 per cent of
every penny expended on Medicare and Med-
icaid since 1966 is of no moment to the analysts.

Likewise, the pharmaceutical manufacturing
industry, an indispensable health care team part-
ner, gets its share of the guff. And the fact that
we have more and better drugs at lower prices
confounds the doomsday analysts not one iota.

Anybody who has been to the supermarket late-
ly or who has shopped for a new car doesn’t need
to be reminded that since 1960, the cost of all
goods and services has risen to 135 from 104 on
the 1957-59 consumer price index. But we are
paying an average of only 54 cents more for a
prescription than we were paying 10 years ago.
The mean cost of the doctor’s Rx today is $3.68,
and six out of 10 preparations speeding our re-
covery now were not even available in 1960.

The Bureau of Labor Statistics has a few in-
teresting figures for us in this connection. We
Americans place high priority on a few things we'd

be just as well off without: We spend $78 per
person per year on alcohol and $48 on tobacco.
For TV sets, the outlay is $45 each and an un-
believable $21 on foreign travel. The barber shop
gets $19 per year, but we shell out an average
of only $18 for prescription drugs.

Although the dramatic court action over the
pricing of antibiotics drew comment about the
“drug cartel,” nothing could be farther from the
truth. The pharmaceutical manufacturing in-
dustry is competitive on many more counts than
price alone. Company struggles against company
for superior quality control, advanced research,
and public service lines from which a profit can
never be realized.

It works, too, because of 868 new drug entities
marketed from 1940 through 1969, The United
States produced 536, while Switzerland intro-
duced 57; Germany, 41; and Great Britain, 40.

The American drugmakers pay their own
freight, too, not just in taxes but in costs of
product development and research. Today, the
federal government pays for 51 per cent of all
research conducted by private industry. The aero-
space group gets 81 per cent of its research
money from the government. The electronics in-
dustry is dependent upon Uncle Sam for 59 per
cent of its development financing, and the Detroit
automakers get 28 per cent.

But the American pharmaceutical manufactur-
ing industry pays 98 per cent of its research costs
and accepts 2 per cent federal financing. Nor is
this a nickel and dime outlay, either, because the
drugmakers will spend $600 million on research
this year.

Put all of this together with the lengthening life
span, lessening incidence of morbidity in selected
disease areas, reduced hospital stays, and all
the rest of the factors making us healthy, and we
find that the drug industry has turned in a worthy
stewardship and remarkable performance. Let
us remember that the most important ingredient
in a prescription drug cannot be seen or analyzed
in the laboratory: It is quality and reliability. And
neither a generic nor brand name drug is any
better than the quality aims of the company that
makes it. Isn’t it nice to know that something we
need so urgently is priced within reason? Especial-
ly when the main thing about it to go up is
quality. — R.B.K.

SEPTEMBER 1970

5 09

EDITORIALS / Continued

Why Not More
Dental Care Insurance?

Seven out of eight Americans have some
form of medical service and hospital insurance
or prepayment plan, but only three out of 100
have dental care coverage. Even the serious stu-
dent of medical and health socioeconomics is
hard put to come by an answer for this health
care financing deficit, especially when dental
care amounts to 10 per cent of our $60 billion
health service expenditure annually.

For many years, an overly simplified answer
was usually given. We were quick to say that
dental care insurance carried with it built-in bank-
ruptcy, because about 80 to 90 per cent of all
dental services are postponable. Generally, in-
surance is based on the concept of risk-spreading
of things which happen quickly and suddenly,
certainly, as opposed to something developing
slowly and progressively. This, for example, is
the reason for built-in time barriers in health
care coverage for maternal services, hernia re-
pairs, and the like.

But the need for dental care coverage is ap-
parent, if we are to believe the figures on the
state of the nation’s teeth. Dental authorities say
that there are between 800 million and a billion
cavities among us quietly rotting away our teeth.
The Surgeon General of the U. S. Public Health
Service says that less than half of the 200 million-
plus Americans were seen by a dentist last year.
Four out of every five Americans over age 15
have some sort of gum disorder, and one child
in four has a malocclusion of such magnitude
that chewing causes facial distortion.

About 6 million Americans have dental ser-
vice coverage, and half of it is written by the
private insurance industry. Dental society service
corporation plans account for the other half, ac-
cording to the Health Insurance Institute. The
Mississippi Dental Association voted to authorize
a dental service corporation some years ago, but
it has not yet been brought into being.

Most tax-supported programs of health care of-
fer only minor and token dental services. Medi-
care and Medicaid are next to nothing, and
CHAMPUS, probably the best and most in-
clusive of all tax-supported plans, has little or
none, generally related to emergency dental care
following injury. Probably more dental services
are offered under the various Head Start programs
than any others in the public sector.

Dental insurance is usually characterized by
a healthy deductible which the patient must pay
after which a 20 to 50 per cent co-pay obligation
is incurred. Under such plans, the assured is
lucky to recover as much as a fifth of his dental
care expense. The dental service corporation is
better, although it is essentially a postpayment
program, usually through an employer group.
Dental service corporations usually adjust rates
on a one year experience basis. And 3 million
out of 200 million Americans served is a tiny
segment.

During the 1st Session of the 91st Congress,
a bill was introduced to add dental care benefits
under the CHAMPUS program for dependents
of those on active duty and the retired military.
While the bill was a stingy measure requiring as
much as $150 in patient-paid deductibles, it
never got out of committee. Reason: Fear of
costs.

The dental profession and organized dentistry
are challenged to discover more about care costs,
actuarial concepts in providing dental prepay-
ment and insurance, and exactly how such bene-
fits may best be offered to the care-consuming
public from within the private sector. Perhaps
the idea of a dental care foundation, patterned
after the western medical care foundations, is an
answer with promising potential.

In any event, the challenge is clear, and the
opportunity for private dentistry to devise an ini-
tiative will never be better than it is today. —
R.B.K.

‘'Put them all together and they spell mother.”

510

JOURNAL MSM A

Ingratitude and Calumny
and Sen. Hughes

Francesco Guicciardini said during the 16th
century that “ingratitude and calumny follow a
gocd deed usually faster than gratitude and re-
ward.” Over 400 years later, the American Med-
ical Association has a case in point proving the
wise Italian correct.

Last March, AMA representatives testified in
support of a bill by Sen. Harold E. Hughes (D.,
Iowa) which would have jurisdiction over drugs
vested in a health agency of government rather
than in the Department of Justice. In May,
two months later, AMA presented testimony in
support of a bill by Sen. Hughes on the treatment
of alcoholism.

Recently, the mercurial senator, a liberal’s lib-
eral, was meeting with members of the American
Alliance for Political Action which happens to
be made up of militant students. Sen. Hughes
was quoted as having said to the group in a dis-
cussion of the nation’s problems that “if the medi-
cal profession — one of the most conservative —
says we are responsible, it could have an effect
on people.”

Having warned the students, the senator ex-

horted them to begin political lobbying “by taking
the American Medical Association on.”

Now, this utterance can hardly be described
as astonishing, coming from Sen. Hughes. What
is astonishing is that he did not toss in a few
adjectives just to make sure that nobody mis-
understood the posture of these right-wing doc-
tors. But the ingratitude and calumny of the whole
thing is the senator’s omission of AMA’s support
of two pieces of legislation which he had pro-
posed. In the light of the exhortation to the
militant students, it can only be reasoned that
the omission was deliberate.

Of course, the medical profession did not offer
its support of the two legislative proposals to ap-
pease or curry favor with Sen. Hughes. AMA
speaks out on legislation only because it seeks
the best interests of the nation’s health. But the
senator might have had the grace to acknowledge
the action.

It is interesting to note that AMA has found
reason to support many positions for which liber-
als as well as conservatives stand: Increases in
the nation’s medical manpower, more and better
training programs for allied professional person-
nel, Medicredit and the principle of a pluralistic
care delivery system, research, and a host of
measures intended to improve and expand care
in the United States.

—The lowest priced tetracycline— nystatin combination available—

II 1 1t it Y< I »V*
■n'.'TVJTN’

Muni s{srt>s

M hrostatin

5 1 1

SEPTEMBER 1970

EDITORIALS / Continued

All of this seems to point in a single direction
and clarify an unmistakable perspective: Men of
Sen. Hughes’ inclinations are inflexible in their
antiestablishment aims, and their actions contra-
dict anybody’s definition of liberalism. If being
conservative means reluctance to toss the system
out the window when it has served us well, then
we are conservatives. Meanwhile, color Sen.
Hughes ungrateful. — R.B.K.

Button Power,
Teenage Style

A group of Salt Lake City teenagers are mak-
ing a success out of a button-making campaign.
Only they are a little different: Instead of
antiwar, antiestablishment, and antieverything
buttons, these youngsters are giving each other
some good advice with a smile.

To date, they have produced buttons in three
campaigns, “Battle Booze,” “Ban the Butt,” and
“Dump Drugs.” On drinking, they have these
messages: “Drinking Pays — the Distillers, the
Hospitals, and the Junkyards.” Another antibooze
button proclaims “Drinkers Have Everything:
Halitosis, Cirrhosis, and Psychosis.” A third one
admonishes “Support Your Local Sheriff —
Drink.” Tobacco brings out the grim side of the
teeners’ thinking with “Little Orphan Annie’s
Parents Smoked.” Another proclaims that “The
Family That Smokes Together Chokes Together.”
On drugs, “Don’t Meth Around” and “Speed
Kills.”

This is one teenage demonstration against so-
cial practices which is to be encouraged and sup-
ported. The tragic permissiveness of society may
finally be most effectively reversed by those for
whom its benefits were mistakenly intended. The
bad angle, however, is that too few realize the
mistake in time. More button power like this to
the teenagers. — R.B.K.

(

FUTURE CALENDAR

October 20

Circuit Course, Tupelo
Circuit Course, Natchez

October 22

Circuit Course, Greenville
October 29

Circuit Course, Greenville
November 4

Pulmonary Seminar (Tentative Date)
November 5

Circuit Course, Greenville

November 17

Circuit Course, Tupelo

November 24

Circuit Course, Columbus
December 11

Gynecologic and Obstetrical
Infections Seminar

January 7, 1971

Circuit Course, Hattiesburg

January 12

Circuit Course, McComb
February 4

Circuit Course, Hattiesberg
February 16

Circuit Course, Natchez
February 23

Circuit Course, Columbus
March 2

Circuit Course, Meridian
March 4

Circuit Course, Hattiesburg
April 6

Circuit Course, Meridian
April 13

Circuit Course, McComb
April 20

Circuit Course, Natchez
April 27

Circuit Course, Columbus

September 22 , 1970

Circuit Course, Tupelo

May 3-6

Mississippi State Medical Association

October 13

Circuit Course, McComb

May 11

Circuit Course, Meridian

512

JOURNAL MSM A

Earl W. Green, Emmett Herring, and John
E. Green of Hattiesburg announce the associa-
tion of Milam S. Cotten for the practice of
ophthalmology at the Green Eye Clinic, 705 Hall
Avenue.

John K. Abide of Cleveland announces the as-
sociation of Perrin N. Smith in the practice of
obstetrics and gynecology at 801 First Street.

S. Lamar Bailey of Kosciusko announces the as-
sociation of his son, James W. Bailey, for the
practice of general medicine and surgery at Bail-
ey’s Clinic, Hwy. 12.

David A. Ball has joined the medical staff at
Batesville Hospital as a general practitioner. Dr.
Ball, a graduate of the University of Mississippi
School of Medicine, has recently returned from
a year’s tour of duty in Vietnam with the U. S.
Air Force.

Jim Barnett of Brookhaven announces the as-
sociation of Jerry Lingle in the general practice
of medicine and surgery at 222 South Church.

Hugh P. Boswell, Jr., a native of New Albany,
has assumed the position of hospital-based
pathologist and director of the department of
pathology at the Northeast Mississippi Hospital
in Booneville.

R. E. Caldwell and W. E. Caldwell of
Baldwyn announce the association of Vernon
A. Chase in the general practice of medicine.
The Baldwyn Medical Group is located on Hwy.
45 South at Mill Street.

David K. Carter is now associated with the
Watkins Clinic in Quitman. Dr. Carter, a recent
graduate of the University of Mississippi School
of Medicine, will practice general medicine.

S. B. Caruthers of Grenada has been awarded a
special certificate of appreciation from the Presi-
dent of the United States for his loyal and faith-
ful service as Medical Advisor to Local Board 23,
Grenada.

James R. Cavett, Jr., of Jackson has been ap-
pointed medical director for Lamar Life Insur-
ance Company.

Henry Holleman of Columbus has been named
chief of staff at Lowndes General Hospital.
Frank Baird was elevated from secretary to vice
chairman and William C. Gates, Jr., was
named secretary of the staff.

W. N. Jenkins of Port Gibson was honored
with a reception at Claiborne County Hospital
for his having served a half-century in the medi-
cal profession. He was also elected to the MSMA
Fifty Year Club.

Earl L. Laird of Meridian has been appointed
by Governor John Bell Williams to the State
Banking Board as a member from the state-at-
large for a term expiring May 1, 1974.

Woodrow Lamb, recently of Greenwood, has
been appointed director of the Coahoma County
Health Department at Clarksdale. He was for-
merly clinician for a five-county district.

A. Eugene Lee of Oxford is the first Mississip-
pi to be admitted as a Fellow of the American
College of Legal Medicine. There are now 142
Fellows in the organization which requires gradu-
ation both from accredited medical and law
schools.

Thomas D. Little announces the opening of
his office for the practice of orthopedic surgery
at 1103 2 1st Avenue, Meridian.

William R. Lockwood of Jackson has been
named to the dual position of Jackson Veterans’
Administration Center associate chief of staff
of research and University of Mississippi Medical
School assistant dean for coordination of research
at the V.A. Center.

C. Foster Lowe announces the opening of his
office at the Surgical Clinic, 620 Delaware Avenue
in McComb. Dr. Lowe limits his practice to
general surgery.

David L. Clippinger, formerly of Hazlehurst, an-
nounces the relocation of his practice at 743 16th
Street in Gulfport in the Mississippi City Shopping
Center.

John Robert Davis of Corinth has joined the
Davis Clinic on Childs Street. Dr. Davis limits his
practice to internal medicine with emphasis in
gastroenterology.

J. O. Manning of Jackson is serving as president
of the Hinds County chapter of the Ole Miss
Alumni Association.

Frank J. Morgan, Jr., of Jackson, and as-
sistant State Health Officer, has been promoted
to the rank of captain in the Medical Corps
of the U. S. Navy Reserve, back dated to August
1969.

5 1 3

SEPTEMBER 1970

His wife has a lot of different
nopausal symptoms, but only a few
lly irritate him. Her hot flashes, her
tigo, her palpitations — that’s her
)blem. What really bothers him is
r nervousness, her irritability and
r excessive anxiety, often expressed
endless “book-shuffling, chain-
oking, reading-lamp’’ insomnia!
Menrium takes care of hot flashes,
rtigo, palpitations in most
mopausal women. Menrium
Dvides the well-known antianxiety
ion of chlordiazepoxide (Librium®)
d water-soluble esterified estrogens,
therefore relieves more symptoms
an either component separately,
takes care of the vasomotor
nptoms as well as the emotional
nptoms. This means the symptoms
at bother his wife most. And the
nptoms that irritate him most.

So, to help them both get through
' menopause, remember Menrium.

Before prescribing, please consult complete product informa*
tion, a summary of which follows:

Indications: Management of manifestations generally associated
with the menopausal syndrome — anxiety and tension, vasomotor
complaints and hormonal deficiency states.

Contraindications: Women with cancer of breast or genitalia,
except inoperable cases, and those with known hypersensitivity to
chlordiazepoxide and/or esterified estrogens.

Warnings: Caution patients about possible combined effects with
alcohol and other CNS depressants. As with all CNS-acting drugs,
caution patients against hazardous occupations requiring complete
mental alertness (e.g., operating machinery, driving). Exclude other
possible causes of menopausal syndrome manifestations, such as
pregnancy. Though physical and psychological dependence have rarely
been reported on recommended doses, use caution in administering to
addiction-prone individuals or those who might increase dosage;
withdrawal symptoms (including convulsions) similar to those seen
with barbiturates have been reported following discontinuance of
chlordiazepoxide HC1. Potential benefits of use in pregnancy, lactation
or women of childbearing age should be weighed against possible
hazards to mother and child. Clinical data inadequate on safety
in pregnancy.

Precautions: In elderly and debilitated patients, limit dosage to
smallest effective amount of chlordiazepoxide (initially 10 mg or less
per day) to preclude ataxia or oversedation; increase gradually as
needed and tolerated. Though generally not recommended, if combina-
tion therapy with other psychotropics seems indicated, carefully
consider individual pharmacologic effects — particularly in use of
potentiating drugs such as MAO inhibitors and phenothiazines.
Observe usual precautions in patients with impaired renal or hepatic
function. Paradoxical reactions to chlordiazepoxide (e.g., excitement,
stimulation and acute rage) have been reported in psychiatric patients.
Employ usual precautions in the treatment of anxiety states with
evidence of impending depression; suicidal tendencies may be present
and protective measures necessary. Variable effects on blood coagula-
tion very rarely reported in patients receiving Librium® (chlordiaz-
epoxide) and oral anticoagulants.

Adverse Reactions: Untoward effects seen with either compound
alone may occur with Menrium. With chlordiazepoxide, drowsiness,
ataxia and confusion reported in some patients, particularly in the
elderly and debilitated; while usually avoided by proper dosage adjust-
ment, these are occasionally observed at lower dosage ranges. Also
reported have been a few instances of syncope; isolated occurrences of
skin eruptions, edema, minor menstrual irregularities, nausea and
constipation, extrapyramidal symptoms, increased and decreased
libido, and occasional reports of blood dyscrasias, including agranu-
locytosis, jaundice and hepatic dysfunction. Periodic blood counts and
liver function tests advisable during protracted treatment. Changes in
EEG patterns (low-voltage fast activity) observed during and after
chlordiazepoxide treatment.

With estrogens, headache, nausea and vomiting, anorexia,
gastrointestinal discomfort, dysuria and urinary frequency, jitteriness,
breast engorgement, formation of breast cysts, skin rashes and pruritus
occasionally seen. Administration may also be associated with
uterine bleeding and/or followed by withdrawal bleeding.

Usual Dosage: One tablet t.i.d. for 21 days, followed by one-week
rest periods.

5 mg chlordiazepoxide

5 mg chlordiazepoxide

0.2 mg water-soluble
esterified estrogens

0.4 mg water-soluble
esterified estrogens

0.4 mg water-soluble
esterified estrogens

10 mg chlordiazepoxide

PERSONALS / Continued

Wren R. Nealy, formerly of Pascagoula, an-
nounces the relocating of his office to 1251 Lan-
caster Drive, Salem, Ore.

J. Elmer Nix of Jackson announces the associa-
tion of Sidney R. Berry for the practice of
orthopedic surgery at Suite 408. Medical Arts
Building.

Joe Robert Norman of Jackson has been named
professor of medicine and Christmas Seal profes-
sor of respiratory disease at the University Medi-
cal Center.

William B. Profilet, Jr., has associated
with the Medical Clinic at 153 E. Center
Street in Canton. Dr. Profilet will practice general
medicine and surgery.

Lamar Puryear, Jr., of Hazlehurst has been
promoted from the rank of colonel in the Missis-
sippi National Guard to Brigadier General. Dr.
Puryear has 29 years of military service in the
guard.

William H. Rosenblatt of Jackson is directing
a series of six short courses, ‘Introduction to
Cardiac Nursing,” at Mississippi Baptist Hospital.

Henry D. Santina and Elizabeth Hollings-
worth of Columbus have announced that Ben

F. Martin has assumed the direction of the
laboratory at Lowndes General Hospital and at
Columbus Pathology Laboratory.

Edsel F. Stewart of McComb has been award-
ed the Physician's Recognition Award for excel-
lence in the profession of medicine for fulfilling
requirements in continuing medical education by
the American Medical Association.

Wendell H. Stockton of Amory has been elect-
ed to fellowship in the American Academy of
Pediatrics.

The Children’s Clinic, 876 A Lakeland Drive in
Jackson, announces the association of Robert
H. Thompson, Jr., for the practice of pediatrics.

Clifford Tillman of Natchez has been ap-
pointed chairman of the MHA Intensive Cardiac
Care Committee for this area of the state.

G. Spencer Barnes of Columbus, president of
the Mississippi Heart Association, made the an-
nouncement.

L. D. Webb of Calhoun City, who is currently
serving as mayor, was honored recently by the

Chamber of Commerce for outstanding service
to the town. He was presented a plaque at the
Chamber banquet.

David B. Wilson of Jackson has accepted a
one-year consultantship in health services plan-
ning with the Coordinator of Health Services,
Office of the Governor, State of Illinois. He will
be working out of Chicago.

W. B. Winstead of Pascagoula has been ap-
pointed to the emergency room physician staff
at Singing River Hospital.

Collins, Ted Zanny, Columbus. Born Jones-
ville, La., Jan. 29, 1931; M.D. Louisiana State
University School of Medicine, New Orleans, La.,
1965; Interned Charity Hospital, New Orleans,
La., one year; Urology residency, same, four
months; radiology residency, same, Nov. 1966-
Oct. 1969; elected July 1970, Prairie Medical
Society.

Kobs, Darcey Gus, Jr., Hattiesburg. Born Gal-
veston, Texas, April 4, 1939; M.D. University
of Texas Medical Branch, Galveston, Texas,
1965; Interned University of Texas Medical
Branch Hospital, Galveston, Texas, one year;
radiology residency, same, six months; radiology
residency. Denver General Hospital, Denver,
Colo., March 16, 1967-Sept. 15, 1969; elected
June 1970, by South Mississippi Medical Society.

Mitchell, Larry Morris, Jackson. Born Ma-
gee, Miss., Jan. 27, 1935; M.D. University of
Mississippi School of Medicine, Jackson, Miss.,
1963; Interned University of Cincinnati, Cincin-
nati, Ohio, one year; internal medicine resi-
dency, University Medical Center, Jackson, Miss.,
July 1964-June 1967; elected May 1970, by
Central Medical Society.

Richardson, Travis Quitman, Ruleville. Born
Aug. 15, 1933, Doddsville, Miss.; M.D. Tulane
University School of Medicine, New Orleans, La.,
1969; Interned St. Joseph Hospital, Houston,
Texas, one year; elected April 1970, by Delta
Medical Society.

5 1 6

JOURNAL MSM A

Book Reviews

Cardiac Arrest and Resuscitation. By Hugh E.
Stephenson, Jr., M.D., F.A.C.S. 500 pages with
223 illustrations. St. Louis: The C. V. Mosby Co.,
1969. $29.50.

This is the third edition of this book, previous
editions having been presented in 1958-64.

This is an attempt to present in one volume
the current total picture of the problems dealing
with cardiopulmonary resuscitation.

His list of references is most adequate. It
amply demonstrates the thoroughness with which
this volume has been presented.

The historical aspect of cardiac arrest and
resuscitation is gone into with detail and is not
only informative but extremely interesting. I
would recommend this not only to physicians but
to nurses and paramedical personnel who are
confronted with this problem. This is particularly
true for personnel who are involved with ambu-
lance driving, helicopter teams and most es-
pecially personnel working with intensive care
and coronary care units. The chapter on recog-
nition of cardiac arrest is of particular interest
to these groups. The methods of diagnosing, treat-
ing and monitoring are presented in this chapter.
Also the following chapter is very explicit on
the techniques of cardiopulmonary resuscitation.

The volume seems to be complete in its presen-
tation. Despite its detail and thoroughness the
book is most pleasant reading. Not only would
it be an excellent reference book, but it should
be handy for all physicians who are dealing with
this particular problem. This book would be of
special interest to anesthesiologists, cardiologists
and cardiac surgeons. I think it would be a must
for a medical school library and would feel that
medical students should be familiar with this
information.

Chapter 50 deals with a very important sub-
ject, the medical-legal aspects of cardiac arrest
and resuscitation, which is often omitted in other
volumes.

In summary, the authors have presented in

one volume in a comprehensive manner the ma-
jor problems dealing with cardiac arrest and re-
suscitation along with problems leading to it and
with its long term followup. I think this would
be a valuable adjunct to any medical library.

Henry B. Tyler, M.D.

Handbook of Legal Medicine. By Alan R.
Moritz, M.D., and R. Crawford Morris, LL.B.
238 pages. St. Louis: The C. V. Mosbv Co.,
1970. $8.75.

The Handbook has appeared in its third edition
with two notable improvements: It is small and
concise, almost abbreviated, and it is almost as
up-to-date as the daily newspaper. For those
who have used the splendid predecessor book.
Doctor and Patient and the Law, in which one
of the present authors. Dr. Moritz, collaborated
with C. Joseph Stetler, LL.B., J.D., the new
Handbook covers familiar subjects with a new
and useful approach.

The work is divided into two major parts. The
first is medicolegal and a synopsis of forensic
pathology. In the brief but highly informative
chapters on death by violence, fixing time of
death, rape, abortion, battered child syndrome,
and associated subject areas, the physician-reader
will find elemental information which he already
knows. The attorney will benefit from these
thumbnail sketches. And both will be given use-
ful references, often, with cases in point by cita-
tion.

By far, the most useful portion to the practic-
ing physician is the second division of the work
which runs the gamut of medicolegal aspects of
practice-encountered situations. An example of
the currency of the book may be found in the
brief chapter on abortion where the authors
summarize actions of state legislatures in liber-
alizing laws, including the “on demand" statutes
enacted in Alaska, Hawaii, and New York. The
pending case, United States of America v. Vuitch,
expected by many legal observers to be the piv-
otal decision in the fall term of the U. S. Supreme
Court in this area, is cited.

The second section on physician and patient

SEPTEMBER 1970

517

THE LITERATURE / Continued

and on the physician and the law lacks the de-
tail and elaboration found in the 1962 work by
Moritz and Stetler, yet its conciseness and brevity
do not impair its usefulness. The physician can
secure information quickly from these chapters
and then properly seek guidance and advice
from legal counsel which should be the case.

In addition to definitive information on con-
sent, negligence, legal insanity, liability, and the
whole spectrum of circumstances likely to arise
in medical practice, the authors have included
pertinent reference information on statutes of
limitations, narcotics regulations, and workmen’s
compensation.

A most useful glossary of medicolegal termi-
nology precedes the index. Citations of cases in
point have been reduced to a bare minimum,
and perhaps the work might be enhanced by
inclusion of additional citations for ready refer-
ence by attorneys. The book is printed on soft
ivory English-finish paper of high quality and at-
tractively bound. It is recommended as a useful
reference to practicing physicians.

Rowland B. Kennedy

New Books Received

The Adolescent Patient. By William A. Dan-
iel, Jr., M.D. 444 pages with 76 illustrations.
St. Louis: The C. V. Mosby Company, 1970.
$20.50.

Spectroscopic Approaches to Biomolecular
Conformation. Edited by D. W. Urry. 314 pages.
Chicago: The American Medical Association,
1970. $15.00.

The Tetralogy of Fallot From a Surgical View-
point. By John W. Kirklin, M.D., and Robert
B. Karp, M.D. 189 pages with 88 illustrations.
Philadelphia: W. B. Saunders Company, 1970.
$13.00.

Healthful School Environment. By Charles C.
Wilson, M.D., and Elizabeth Avery Wilson,
Ph.D. 296 pages. Washington, D. C.: The Na-
tional Education Association and the American
Medical Association, 1969. $6.00.

Emergency Treatment and Management. 4th
Edition. By Thomas Flint, Jr., M.D., and Harvey
D. Cain, M.D. 733 pages with 22 illustrations.
Philadelphia: W. B. Saunders Company, 1970.
$11.50.

5 1 8

Grant, Roy Gilmer, M.D., University of Vir-
ginia School of Medicine 1919; Interned Orange
Memorial Hospital, Orange, N. J., one year; died
July 17, 1970, age 77.

Microbiologist Studies
Sterility Evaluation

A leading microbiologist has unveiled promis-
ing new concepts for sterility evaluation. Armand
Marinaro, chairman of the Sterility Subcommittee
of the Health Industries Association’s Sterile
Disposable Device Committee and assistant to the
director of Technical Assurance and Services at
Johnson & Johnson Company, outlined newer
procedures recently at the 70th Annual Meeting
of the American Society for Microbiology in
Boston.

“The use of a sterility test by itself is inade-
quate . . . ,” Marinaro points out. “Other factors
must be introduced to maintain a successful steril-
ity program.” The microbiologist says more than
one agent, and several methods of procedure must
be used together or in succession.

Marinaro’s approach includes the use of pur-
posely inoculated samples placed at pre-deter-
mined locations throughout the lot or batch.
This is done once the exact method of sterili-
zation has been selected. During this phase of
exploration, Marinaro finds the microorganism
that is most resistant to the conditions of the
sterilizing process to be used. This microorganism
then becomes a measuring tool against which the
microbiologist can measure his test using rela-
tively few samples.

Marinaro does not permit the control proce-
dure to become static. He constantly attempts to
find microorganisms that are more resistant than
those being used. These control microorganisms
are placed at strategic locations in the batch, and
the entire sample is then subjected to a standard
sterility test as outlined in the current U.S.P.

Complete copies of Marinaro’s presentation
have been made available through the HIA’s
Sterile Disposable Device Committee office. Cop-
ies are available at $5.00 each by writing to
HIA/SDDC, Suite 314, 1225 Connecticut Ave-
nue, N. W., Washington, D. C. 20036.

JOURNAL MSMA

New Membership Service Will Itemize
Dues and Offer Tax Deduction Records

A new membership service will be initiated in
October to make dues payment easy for members
and component medical societies. The service was
authorized by the House of Delegates at the May
1970 annual session and ordered implemented by
the Board of Trustees.

Drs. Paul B. Brumby of Lexington, association
president, and Mai S. Riddell, Jr., of Winona,
Board chairman, said that many benefits will ac-
crue in the new service, including furnishing of
itemized statements to members for all payments,
complete records to local society secretaries, and
greater convenience for all.

“Much thought and planning have gone into
this new program,” Drs. Brumby and Riddell
said. “It is a maximum-accuracy and maximum-
convenience program with complete records for
the individual physician and his local medical
society furnished.”

Billing statements will be prepared and mailed
from the state medical association’s Jackson exec-
utive office, the announcement stated. Even a
postage-paid return envelope will be furnished for
the convenience of members.

The statement will list in detail both amounts
to be paid and exact identification of each. These
include local, state, and AMA dues, all of which
are fully deductible for income tax purposes.

Also included for physicians’ convenience will
be items for MPAC (Mississippi Medical Poli-
tical Action Committee) and AMP AC (Ameri-
can Medical Political Action Committee) dues.
These amounts, $10 each for 1971, are volun-
tary and nondeductible for tax purposes. The
reason is that these are used for direct political
action purposes in behalf of medical organization.

Statements will contain a reminder for AMA-
ERF (American Medical Association Education
and Research Foundation) gifts, which are volun-
tary and fully tax deductible. Members may ear-
mark their AMA-ERF gifts for the medical
school of their choice, if desired.

No part of PAC dues or AMA-ERF gifts go
for administrative or collections costs. These are
jointly borne by the organizations which are to-

tally and completely separate from the state
medical association and AMA.

The detailed, itemized statements, fully accept-
able for income tax records, will be mailed about
Oct. 15, according to Dr. Raymond S. Martin,
Jr., of Jackson, association secretary-treasurer.
Each mailing will also carry a postage-paid return
envelope for the convenience of the remitting
member.

The state executive staff will process dues and
gift returns on a daily basis, making complete
reports to the members’ local societies, PAC or-
ganizations, AMA, and to the AMA-ERF. The
service is expected to relieve local society secre-
taries of time-consuming tasks and improve
records at their disposal.

Early collections will also establish income
tax deductions, both with the itemized documen-
tation and cancelled check.

Drs. Brumby, Riddell, and Martin appealed to
members to respond promptly to billings for their
own benefit as well as for local societies and the
state medical association.

“We plan to perform this service for the mem-
bers and their societies without charge and with-
out adding a single additional staff member in the
executive office,” the association leaders said.

“To do this, we need to get this task behind us
before the end of the year, because we will need
maximum staff services for the new and expanded
legislative program and the annual session of
the legislature,” they added.

Members who are exempt from dues, includ-
ing Emeritus members and those in residencies
or the military service, will not be billed. They
will receive their membership cards after certifica-
tion by the local society.

The entire service is under control of the local
societies which will approve each billing before
it is made.

New members will submit application forms
and their checks to local secretaries as before.
The program has been well-received, officials said,
and it is expected to increase efficient operations,
offer convenience and better records to members,
and assist local societies.

SEPTEMBER 1970

519

s worth doing well

Take ACHROMYCIN V, for example. Lederle routinely
runs over 1 ,000 quality control checks on every batch
produced. Many, many more than officially required. This
extra attention means your patients get what the doctor
ordered when you prescribe ACHROMYCIN V: uniform
in vitro dissolution rate, predictable in vivo serum and urinary
levels. In short, known biologic availability of tetracycline.

And every step in the production of ACHROMYCIN V is
in-house controlled right in Pearl River.

ACHROMYCHT-V

Tetracycline HCI

Performance proved in practice

ectiveness: ACHROMYCIN
tracycline is a crystalline broad-
ectrum antibiotic which provides
ective therapeutic activity against
sceptible microorganisms.

' ntraindication : History of
persensitivity to tetracycline.
irning: In renal impairment, usual
ses may lead to excessive
cumulation and liver toxicity. Under
ch conditions, lower than usual doses
3 indicated and, if therapy is
Dlonged, serum level determinations
iy be advisable. Some patients may
velop a photodynamic reaction to
tural or artificial sunlight. Those with a
story of photosensitivity reactions
ould avoid direct exposure to sunlight
lile under treatment. Discontinue drug
first evidence of skin discomfort.
scautions: Use may result in
ergrowth of nonsusceptible organisms.

Constant observation is essential. If new
infections appear, take appropriate
measures. Use of tetracycline during
teeth development may cause
discoloration of teeth.

Side Effects: Gastrointestinal system-
anorexia, nausea, vomiting, diarrhea,
stomatitis, glossitis, enterocolitis, pruritus
ani. Skin— maculopapular and
erythematous rashes (a case of
exfoliative dermatitis has been reported);
photosensitivity reaction, onycholysis
and discoloration of nails (rare). Kidney-
rise in BUN, apparently dose-related.
Hypersensitivity reactions— urticaria,
angioneurotic edema, anaphylaxis. In
young infants, bulging fontanels have
been reported following full therapeutic
dosage. This symptom has disappeared
rapidly when drug is discontinued. Teeth
—dental staining (yellow-brown) in
children of mothers given tetracycline

during the latter half of pregnancy, and in
children given the drug during the
neonatal period, infancy and early
childhood. Enamel hypoplasia has been
seen in a few children. Blood— anemia,
thrombocytopenic purpura, neutropenia,
eosinophilia. Liver— cholestasis (rare),
usually at high dosage. Tetracycline may
form a stable calcium complex in bone-
forming tissue. If adverse reaction or
idiosyncrasy occurs, discontinue medica-
tion and institute appropriate therapy.
Average Adult Daily Dosage: One Gm.
per day, in 4 divided doses of 250 mg.
each. Should be given 1 hour before or
2 hours after meals, since absorption is
impaired by the concomitant
administration of high calcium content
drugs, foods and some dairy products.
Treatment of streptococcal infections
should continue for 1 0 days, even
though symptoms have subsided.

LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 10965

281-0

ORGANIZATION / Continued

Drug Abuse
Exhibit Is Available

An exhibit on drug abuse may now be obtained
on loan from Eli Lilly and Company by state,
county, and local pharmaceutical and medical
associations and by schools of pharmacy and
medicine. The exhibit is designed for display
at state or county fairs, health fairs, or other ap-
propriate gatherings of the general public under
the sponsorship of the association and/or school.

The eight-foot-long exhibit features an 11-
minute slide-tape presentation entitled “Students
Look at Drugs,” in which six students describe
the availability and use of drugs as they see them
and offer suggestions for alleviating the problem.

Space is provided above the film screen for
identification of the sponsoring organization. To
the left of the exhibit is a storage compartment
on the top of which handouts such as drug abuse
educational material, health information pamph-
lets, or other literature may be placed for distri-
bution to visitors.

A LaBelle tape cartridge deck is used with a
carousel slide projector to advance the slides auto-
matically and provide narration. The unit runs
continuously.

Although relatively maintenance-free, the unit

Three teenagers discuss the Eli Lilly Exhibit on
drug abuse. This exhibit is now available to pro-
fessionals and medical organizations.

is subject to failure, as with any piece of equip-
ment containing moving parts. For this reason,!
any organization borrowing the exhibit should ar-
range to have someone on hand at all times
during the show hours.

Eli Lilly and Company will pay shipping costs
to the exhibit site and return to Indianapolis. Any
cost involved in obtaining the exhibit space must
be borne by the sponsoring organization.

A limited number of exhibits are now avail-
able for loan and may be obtained on a first-
come, first-served basis.

The following information is required: (1)
name and dates of the show, including set-up
date; (2) the exact name of the sponsoring
organization; (3) precise shipping instructions
(e.g., street address, building name, booth num-
ber); and (4) the name and address of one in-
dividual who will assume responsibility for setting
up the exhibit, seeing that it is properly manned
during show hours, and seeing that the exhibit is
dismantled, repacked, and returned promptly to
Indianapolis. Note: Two men are required to set
up the exhibit as well as dismantle it. Instructions
accompany the exhibit.

One to three weeks are required to ship to
location, depending on the distance from Indian-
apolis.

Requests should be addressed to Eli Lilly and
Company, marked for the attention of the Pro-
fessional Relations and Services Department,
M-501, Indianapolis, Indiana 46206.

ACP Presents
Internal Medicine Course

The American College of Physicians will pre-
sent a postgraduate seminar on basic mechanisms
in internal medicine Oct. 5-9, 1970, at the Medi-
cal College of Virginia at Richmond.

Dr. W. T. Thompson, Jr. is director. Co-direc-
tors are Drs. Charles M. Caravati and Kinloch
Nelson. The minimum number of registrants is
100 and the course is limited to 200.

The purpose of this course is to present new
and significant advances in internal medicine with
emphasis on basic mechanisms and patho-physio-
logic concepts as they relate to clinical manifesta-
tions and to therapy of disease.

522

JOURNAL MSM A

Line of Microsurgical
Instruments Introduced

An extensive line of new interchangeable micro-
surgical instruments, designed for use in the fields
of neurosurgery, eye surgery and the micro-
scopic sciences, is now available from Circon
Corporation, Goleta, Calif.

The Circon microsurgical instruments are com-
pared in size to a dime.

Termed “Circon MicroSurgical,” the new line
consists of 23 micro scalpels, needles and manipu-
lators . . . including three tips which have not been
available even in larger size instruments. One of
these is a Tungsten Ultra MicroNeedle having a
6 micron radius at the point. Another is a unique
Guarded MicroHook which allows withdrawal of
material through a membrane without danger of
the membrane being caught on the hook. Still
another, Circon's MicroSurgical MicroScale is
graduated in 50 micron divisions and permits
visual or photographic measurements.

The unique features of the new microsurgical
instrument line are the ultra micro size of the
working tips, the wide range of tip designs and
the option of having interchangeable tips ground
onto a variety of shaft configurations. A choice
of two delicately balanced handles, designed spe-
cifically for precision work under the microscope,
extends the choice of combinations even further.
Each of the 23 tips may be ordered on any of

the 13 shafts and mounted on either handle to
comprise a total of 598 different instruments.

The complete line of working tips includes
micro needles, micro hooks, micro forks, micro
retractors, micro knives, micro lances, micro
chisels, micro saws, micro spoons, micro spatulas,
micro loops, micro brushes and the micro scale.
A choice of 13 shafts (in 9, 6 or 3 cm. lengths)
and two stainless steel handles (tapered or
straight) are also available for any tip configura-
tion. Handles feature a hexagonal grip and are of
a size and weight which have been found to be
ideal for precision, long duration work under the
microscope.

The new instruments are manufactured of the
finest stainless steel and may be selected individ-
ually or combined in sets. Shafts with tips may be
ordered with or without handles for use in micro
manipulators.

For additional information, write Circon Cor-
poration, Santa Barbara Airport, Goleta, Calif.
93017.

Meridian Gets
Mental Health Center

The Department of Health, Education and
Welfare has approved a $160,000 grant for the
construction of the Weems Region 10 Complex
in Meridian as a community mental health center
serving Clarke, Jasper, Kemper, Lauderdale,
Neshoba, Newton and Scott counties.

The center’s application for $273,000 for ini-
tial staffing of the center also was approved, but
the Regional Commission has been informed that
funding of the staffing grant will be delayed be-
cause insufficient federal funds are available at
this time.

In its approval notification, the Region 10 pro-
gram was commended by the National Institute of
Mental Health for its “exceptionally innovative
and progressive approach in the establishment of
a mental health center.”

Dr. Dorothy Moore, program director of the
Mississippi Interagency Commission on Mental
Illness and Mental Retardation, stated that it was
difficult to predict how long the center’s staffing
funds will be delayed. While construction is in
progress and prior to receipt of staffing funds,
minimal services will be provided in the region by
a small staff supported entirely by local funds.

Dr. William M. Wood will be psychiatrist-
director of the new center program, and Dr. Reg-
inald P. White is chairman of the Region 10
board of commissioners.

523

SEPTEMBER 1970

ORGANIZATION / Continued

Many Use
Yellow Pages

A recent Yellow Pages National Consumer
Usage Study shows that 23.5 per cent of the total
active market use the Yellow Pages to find
pharmacies in a given year. They average 7 uses
per person, totaling more than 141 million per
year.

The study was based on extensive personal
interviews conducted throughout the nation by
Audits & Surveys Co., Inc., an independent re-
search organization.

Seven out of ten adults in the United States or
47,181,000 women — 74 per cent of all 20 years
old and older — and 38,480,000 men — 69 per cent
of the total, are in the market for pharmacy prod-
ucts or services each year.

The study also shows that the more adults in
a household, the more likely they are to seek

pharmacies. Three-fourths of those in households
with five or more adults are in the market, com- L
pared with 70 per cent of those in households
with one to four adults.

Also, 74 per cent of adults in metropolitan
areas seek pharmacy products or services, com-
pared with 68 per cent of those who live in non-
metro areas.

Overall, 71 per cent are for personal reasons,
29 per cent are for business use. However, wom-
en’s uses are reported to be 36 per cent for
business reasons, 64 per cent personal, while
men’s uses run 90 per cent personal, 10 per cent
for business.

Significantly, 37 per cent of all references are
made without the name of a pharmacy in mind.

In terms of income, 28 per cent of those with
incomes of $10,000 and over use the directory,
compared with 25 per cent of those in the $5,000-
$10,000 category, and 15 per cent of those with
family incomes of $5,000 and less.

Also, new residents tend to use the Yellow
Pages considerably more than would be indicated

THE ACTIVE MARKET FOR PHARMACIES

More than 85.6 million of the nation’s 119.8
million men and women (20 and older) annually are
in the market for Pharmacy Products and Services.

FAMILY INCOME NEW-OLD RESIDENTS

Source 1970 Yellow Pages National Consumer Usage Study

Table 1

23.5%— over 20 million people-
use the Yellow Pages
to find Pharmacies.

63% KNOW
PHARMACY -USE
YELLOW PAGES ANYWAY

37% HAVE
NO PHARMACY
IN MIND

29% ARE FOR
BUSINESS REASONS

AVERAGE
7 USES
PER PERSON

141 MILLION REFERENCES

94%

ARE FOLLOWED
UP WITH A

...VISIT

OR LETTER

524

JOURNAL MSMA

for the bacterial complications of flu/Cl.R.I.and related symptoms

Congestion

ection

Fever

Pain

jroad-spectrum An analgesic/antipyretic to bring down
ibiotic to combat fever, ease pain, ana malaise
iceptible
derial infections

Tetrex

An antihistamine
for the

symptomatic relief
of nasal congestion

APG

with Bristamin®

(tetracycline phosphate complex with analgesics and antihistamine)

complete information consult Official
age Circular. (5) 4/2/70.
ations: Upper respiratory infections
a sensitive bacteria where concomitant
tomatic relief of fever, malaise and
astion is desired.

aindications: Hypersensitivity to one or
components.

ings: Photodynamic reactions have
produced by tetracyclines. Natural
rtificial sunlight should be avoided dur-
herapy. Stop treatment if discomfort
s. With renal impairment, systemic
nulation and hepatotoxicity may occur,
s situation, lower doses should be used
serum estimations may be necessary

during prolonged therapy. Tooth staining
and enamel hypoplasia may be induced dur-
ing tooth development (last trimester of
pregnancy, neonatal period and childhood).
Precautions: Antihistamines may cause
drowsiness and patients should not perform
tasks requiring mental alertness while tak-
ing this agent. Bacterial or mycotic superin-
fections may occur. Infants may develop
increased intracranial pressure with bulging
fontanels. Cases of gonorrhea with a sus-
pected primary lesion of syphilis should
have darkfield examinations before receiv-
ing treatment. In all other cases where con-
comitant syphilis is suspected, monthly
serological tests should be performed for a

minimum of 4 months.

Adverse Reactions: Glossitis, stomatitis,
nausea, diarrhea, flatulence, proctitis, va-
ginitis, dermatitis and allergic reactions
may occur.

Usual Adult Dose: 2 capsules q.i.d. Children
6 to 12 years of age: Vz the adult dose.

Continue therapy for at least ten days in
Group A beta-hemolytic streptococcal in-
fections. Administer 1 hour before or 2
hours after meals.

Supplied: Capsules— in bottles of 24 and 100.

A.H.F.S. Category 8:12

BRISTOL LABORATORIES
Division of Bristol-Myers Co.
Syracuse, New York 13201

BRISTOL

ORGANIZATION / Continued

by their proportionate share of the market. Thirty-
one per cent of those who have lived in their
homes two years or less go to the Yellow Pages
to find pharmacies, compared to 21 per cent of
longer-term residents.

Renters, too, are more likely to use the Yellow
Pages, with 25 per cent seeking pharmacies in
this manner, compared with 23 per cent of home-
owners.

Of those who are in the market, metropolitan
area residents also are most likely to use the
Yellow Pages, with 25 per cent doing so, com-
pared with 21 per cent of those who live in non-
metro areas.

Young adults tend to use the directory to find
pharmacies to a greater extent than older people,
30 per cent of those in the 20-39 age group do so,
compared with 19 per cent of those over 40.

The study is said to be the most specific ever
conducted on consumer use of the directory. Na-
tionally, it found that 76.8 per cent of the adult
population refer to the Yellow Pages annually to
find suppliers of all products and services.

Five-Day Course
Set For Internists

The American College of Physicians (ACP)
will sponsor a five-day postgraduate course on
“Advances in Internal Medicine” Sept. 14-18
in San Francisco.

The course will be held at the Department of
Medicine of the University of California San Fran-
cisco Medical Center. It is one of 25 formal and
in-depth postgraduate courses the College is con-
ducting in the United States, Canada and Mexico
during the academic year 1970-71. Each course
is designed to help specialists keep abreast of
new knowledge in the prevention, diagnosis and
treatment of disease.

The San Francisco course will be a review of
selected areas of special interest to internists. In-
cluded will be course material on advances in
cardiology, gastroenterology, pulmonary disease,
endocrinology and metabolic diseases, kidney
disorders, rheumatic diseases and drug therapy.

Dr. Marvin H. Sleisinger, San Francisco, Pro-
fessor of Medicine at the San Francisco Medical
Center, is course director. The faculty will be
drawn largely from the university medical school.

For registrations and applications write Dr. Ed-
ward C. Rosenow, Executive Director, Ameri-
can College of Physicians, 4200 Pine Street, Phil-
adelphia, Pa. 19104.

Snavely Medical
Library Dedicated

Contributions from former students, colleagues and
patients of the late Dr. J . Robert Snavely have es-
tablished a library in his memory in the University
of Mississippi School of Medicine Department of
Medicine. The noted physician-educator was first
medicine chairman at the Medical Center and served
in that capacity until his death in 1964. Talking with
Mrs. Snavely at the reception which followed the
library dedication are three former students of Dr.
Snavely: Dr. Robert E. Tyson of Jackson, left; med-
icine assistant professor Dr. Walter Treadwell, sec-
ond left; and medicine resident Dr. Cecil Williams,
right. Future gifts to the Snavely fund will be used to
expand the collection.

UMC Trains Medical
Record Librarians

Mississippi’s first baccalaureate degree program
for medical record librarians gets underway this
fall at the University Medical Center.

Approved by the Board of Trustees in May,
the program extends and restructures the UMC
certificate training course in operation since 1959.

Candidates for the bachelor’s degree in medi-
cal records must now acquire three-years’ credit
toward their degree at an affiliated college or
university which will grant the degree on comple-
tion of the 11 -month Medical Center course.
Applicants who already hold a bachelor’s degree
must have had the necessary liberal arts courses
outlined in the curriculum.

Coordinated through the UMC Office of Al-
lied Health Professions, the program was changed
to the baccalaureate level in keeping with the
University’s educational goals and the American
Medical Record Association’s registry require-
ments.

526

JOURNAL MSM A

Field Hospital Gets
Lifeguard System

The Field Memorial Community Hospital in
Centreville recently equipped two rooms with a
Modular Lifeguard System, according to Earl Du-
Bose, administrator.

The lifeguard system is designed for the care
of acute coronary patients and for monitoring
other critically ill patients.

The system provides continuous monitoring of
both rooms on a central monitor located at the
nurses’ station. Each patient’s ECG and heart rate
is presented on an oscilloscope and a separate
rate meter so that at a glance the nurse can tell
the heart rate of each patient.

The attending physician may observe the pa-
tients’ ECGs on the oscilloscope either at the nurs-
ing station or on the oscilloscope located in the pa-
tient’s room.

ACP Plans Kidney
Disease Course

The American College of Physicians (ACP)
will sponsor a three-day postgraduate course on
“Renal Diseases: Pathophysiology, Diagnosis

and Management” Sept. 9-11 in Rochester, Minn.

The course will be held at the Mayo Graduate
School of Medicine, University of Minnesota and
the Mayo Clinic for specialists in internal medi-
cine and related specialties. It is one of 25 formal
and in-depth postgraduate courses the College is
conducting in the United States, Canada and
Mexico during the academic year 1970-71. Each
course is designed to help specialists keep abreast
of new knowledge in the prevention, diagnosis
and treatment of disease.

The Rochester course is designed to help in-
ternists with practical problems in diagnosing and
treating kidney diseases and to help them achieve
a better understanding of the disease pathology.
Subjects to be covered will include high blood
pressure and its relation to kidney diseases, kid-
ney stones, glomerular disease and infections of
the urinary tract.

Dr. James C. Hunt, Rochester, Chairman of
the Division and Consultant in Nephrology and
Internal Medicine at the Mayo Clinic and Pro-
fessor of Medicine at the Graduate School, is
course director. He is assisted by Drs. Lynwood
H. Smith and Cameron G. Strong, both of Roches-
ter and the Mayo Clinic. The faculty will be

drawn largely from the Mayo Graduate School.

For registration and applications write Dr. Ed-
ward C. Rosenow, Jr., Executive Director,
American College of Physicians, 4200 Pine Street,
Philadelphia, Pa. 19104.

Dr. Carter Resigns
As UMC Director

University of Mississippi Chancellor Porter
Fortune, Jr., has announced that Dr. Robert E.
Carter, University Medical Center director, has
resigned effective October 1. Also the medical
school dean, Dr. Carter will go to the University

of Minnesota to de-
velop and establish a
new medical school in
Duluth.

A native Minneso-
tan who got both his
undergraduate and his
M.D. degrees from
the University of Min-
nesota, Dr. Carter
completed his intern-
ship at Cleveland City
Hospital, Ohio, and
did postgraduate train-
ing in pediatrics at
the University of Chi-
cago Clinics. He is certified by the American
Board of Pediatrics.

Dr. Carter served in the medical corps of the
U. S. Navy from 1951-53 attaining the rank of
Lieutenant Commander. He is a member of the
state medical association and the American Medi-
cal Association.

He came to the University of Mississippi Medi-
cal Center in 1967 after having been an associate
dean and professor of pediatrics at the University
of Iowa College of Medicine.

His appointment as Dean of the Basic Sciences
Program for Medical Education at the University
of Minnesota Duluth campus was confirmed at a
recent Minnesota Board of Regents meeting in
Minneapolis.

In announcing Dr. Carter’s decision to take up
the newly created and challenging position. Chan-
cellor Fortune praised the medical educator’s keen
interest in medical education. “He has made a
lasting contribution to the University Medical
Center by his confident leadership during a period
of severe stress for all medical schools,” the
Chancellor stated. An advisory committee will be
named soon to recommend a successor, he said.

Dr. Carter

SEPTEMBER 1970

527

ORGANIZATION / Continued

Dr. Brumby Honored
By Hospital Board

The Board of Trustees of Holmes County Com-
munity Hospital has passed a resolution honor-
ing Dr. Paul B. Brumby of Lexington, president
of the Mississippi State Medical Association. The
Board commended the Holmes County native for
his many years of selfless service and expressed
good wishes for his year as MSMA president.

The resolution is as follows :

“Whereas, Dr. Paul B. Brumby was born at
Goodman, in Holmes County, Mississippi, in
1902; received his medical education and degree
at the University of Texas in 1929, followed by
internship at Shreveport Charity Hospital and
further training at New York City Polyclinic and
Harvard University; and returned to his native
Holmes County to practice medicine in 1930;

“Whereas, Dr. Paul B. Brumby has remained
in medical practice in Holmes County, except for
military service during World War II, during
which he attained the rank of Major as a medical
service officer and was awarded the Bronze Star
for gallantry in action on Saipan in the Pacific
in 1945;

“Whereas, During the course of his profes-
sional career. Dr. Paul B. Brumby has rendered
valuable and unselfish service to his nation and
his state, including long service as members of
the Councils on Legislation, Medical Service and
Scientific Assembly of the Mississippi State Medi-
cal Association and Chairman of that Associa-
tion’s Section on General Practice;

“Whereas, By his years of selfless service
of the highest professional order, Dr. Paul B.
Brumby has endeared himself to Holmes County,
and the community served by Holmes County
Community Hospital, and has contributed greatly
to the health care of that community by valuable
contributions of time and service as a member and
officer of the Medical Staff of Holmes County
Community Hospital and

“Whereas, The leadership of Dr. Paul B.
Brumby has been particularly recognized by his
professional colleagues, who have but recently
elevated him to the Presidency of the Mississippi
State Medical Association, a position making
great personal demands for service as well as
a position of high honor and trust;

“Now, Therefore, Be It Resolved by the Board
of Trustees of Holmes County Community Hos-
pital that they do hereby express to Dr. Paul B.
Brumby the deep appreciation of that board and

the community at large for his years of profes-
sional and personal service and that they do here-
by express the highest wishes of all concerned
for his continued success in his undertaking the
office of the Presidency of the Mississippi State
Medical Association, as well as in the future
years of professional service that lie before him;
and Be It Further Resolved that a suitable copy
of this Resolution be presented to Dr. Paul B.
Brumby and his family.”

UMC Ups Freshman
Class to 95

The University of Mississippi School of Medi-
cine has upped the fall freshman class to a record
95, according to Dr. Robert E. Carter, dean.

The five-student increase over last year’s in-
coming class marks the third expansion since
the four-year school opened in 1955, Dr. Carter
said. The additional state appropriations which
helped fund the extra student load came in a
direct effort to meet Mississippi’s overwhelming
need for physicians.

Medical Center
Adds to Faculty

Recent faculty additions to the University of
Mississippi School of Medicine include one assist-
ant professor and four instructors.

The combined fulltime nursing and medical
faculties at the University Medical Center now
top the 200 mark.

Dr. Virginia Read joins the School of Medi-
cine after three years as a fellow at the University
of Alabama at Birmingham. Dr. Read, who for-
merly served as UMC biochemistry instructor and
assistant professor from 1965 to 1968, received
the B.S. degree from the University of Mississippi
and the Ph.D. degree at the University Medical
Center.

Three of the new instuctors are in the radiology
department, Dr. C. James Kees, Dr. John Gib-
son and Dr. Clifton L. Hester. Dr. James Nor-
man McLeod, III, is medicine instructor and chief
resident.

528

JOURNAL MSMA

Image Systems Offers
Microfiche Camera

A new, low cost, table top step and repeat
microfiche camera is offered by Image Systems,
Inc., California based manufacturer of CARD
System equipment.

A table top step and repeat microfiche camera has
been introduced by Image Systems, Inc. and sug-
gested for professional use.

Using standard 105mm roll microfilm, the
Image Systems Microfiche Camera is available
in a choice of 5 popular formats — NMA,
COSATI, COM 80, COM 84 and Decimal
10 x 10 with appropriate reduction ratios es-
tablished between 20 and 30 diameters. Day-
light magazines are included to permit camera
loading and unloading in normal light.

Priced at $5,750, this precision built camera
is capable of producing microfiche from black
and white or color originals in letter, legal or
computer printout sizes at true production rates
and with film quality equal to or exceeding that
obtained in similar equipment regardless of price.

Simplified controls include regulation of light
intensity, exposure, frame position, fiche advance,
x-y platen advance and fiche counter. The cam-
era, designed to complement an office environ-
ment, may be operated by clerical personnel with
minimum training. No special wiring is needed.

The camera is one of a series of modestly
priced equipment pieces produced and marketed
by Image Systems, Inc. When combined, the
system permits the recording, processing, titling

and duplication of microfiche on the user’s prem-
ises under normal light conditions.

For dealer information, write: Image Systems,
Inc., Department MS, 11244 Playa Court, Culver
City, Calif. 90230.

Blind Rehabilitation
Center Begun

Construction has begun on the Addie Mc-
Bryde Memorial Rehabilitation Center for the
Blind, a three-story structure costing over a mil-
lion dollars, as an east wing of the University
Medical Center in Jackson.

In 1968 the Mississippi Legislature appropri-
ated $225,000 state funds for the construction of
this comprehensive rehabilitation center.

The first floor of the building will contain
administrative offices, offices of the non-teaching
staff, a conference area, and several teaching de-
partments with offices.

Second floor will house the other teaching de-
partments, a number of afterhour activities, the
cafeteria and a state training stand which will
provide short order food service for center per-
sonnel, clients, Medical Center staff and visitors
to the complex.

The third floor will contain the dormitory area
with an apartment for the dormitory supervisor.
Proximity to the University Medical Center will
enable the Center for the Blind to utilize medical
specialties which would not be available in an-
other location.

District counselors of Rehabilitation Services
for the Blind, a division of the State Department
of Public Welfare, will utilize the rehabilitation
center to provide at least two fundamental ser-
vices for many of their clients before these
clients move into vocational training and em-
ployment. These services include evaluation to
determine the skills that he needs in order to ad-
just to his environment and training in order to
develop these skills.

Among the skills taught will be mobility, which
should enable him to travel independently; per-
sonal management for himself and his household;
communication skills, and personal adjustment
skills.

Emphasis will also be given to the develop-
ment of recreational skills, which will enable
these handicapped individuals to enjoy and profit
from leisure time.

The Center for the Blind will also provide
experience in working with blind patients for
University Medical Center students and staff.

SEPTEMBER 1970

529

ORGANIZATION / Continued

ICS Schedules
Third Congress

The International College of Surgeons has
scheduled its Third Western Hemisphere Congress
for Las Vegas, Nev., Nov. 20-24, 1970.

For further information write Dr. Aldo Paren-
tela, International Executive Secretary, 1516
Lake Shore Drive, Chicago, 111. 60610.

ACP Discusses
Health Care Issues

The American College of Physicians (ACP)
is urging its 16,000 members in communities
throughout the country to exert local leadership
in eliminating duplication of equipment, services
and personnel among private, voluntary and pub-
lic hospitals.

The College’s Board of Regents sees this du-
plication as one of the reasons for the rising costs
of medical care in the United States, costs which
“must be controlled” by halting competitive plan-
ning among voluntary hospitals, private hospitals
and such government hospitals as those operated
by the Veterans Administration and the Armed
Forces.

The Board of Regents’ resolution, one of two
major policy statements on health care issues,
is published in the current issue of The Bulletin
of the ACP, now being distributed to the College
members. They are specialists in internal medi-
cine and related specialties, most of whom have
hospital staff appointments.

In a second statement, the ACP Board labeled
Federal support of medical school teaching pro-
grams “erratic, sporadic and inadequate” and
called for the alleviation of the “urgent manpower
crisis ... as quickly as possible to improve the
availability and quality of medical services.”

The ACP Regents not only recommend “in-
creased, sustained and better planned” direct sup-
port of teaching programs, but also expanded sup-
port of research programs and continued reim-
bursement of teaching physicians for services they
provide to patients.

The presence of research programs help the
medical schools to recruit more and better teach-
ers, the College statement explains, “because re-
searchers working in medical schools contribute
substantially to the teaching of medical students
and make it possible to increase the number of

students and the quality of their education.”

Dr. Edward C. Rosenow, Jr., Philadelphia, Pa.,
Executive Director of the American College of
Physicians, said the Board statements were is-
sued to fulfill one of the major objectives of
the medical specialty society — to maintain the
“efficiency” of the internal medicine “in relation to
public welfare.”

UMC Expands
Newborn Facilities

The University Medical Center is intensifying
its efforts to reduce Mississippi’s high infant
mortality rate with expansion of special care pro-
grams for newborn babies.

State and federal funds are combining to sup-
port the attack.

According to UMC director Dr. Robert E.
Carter, the 1966 state legislature allocated match-
ing funds for the essential link in the program,
the new 82-bed nursery and newborn intensive
care unit under construction atop the Medical
Center Children’s Hospital. A $95,000 federal
award, matched with UMC service to bring
the total to $137,000, will provide the dollars for
assembling the highly skilled staff required to
give critically ill babies special care and to teach
Mississippi health professionals the latest tech-
niques for helping sick newborns.

Announced recently, the grant from the Depart-
ment of Health, Education and Welfare Maternal
and Child Health Services division is one of five
of its kind awarded across the nation this year.
The United States, points out program director
Dr. Alfred W. Brann, Jr., ranks 15th in the world
in infant mortality. “The other four awards will
be used throughout the country to attack the
problem in much the same way as the Medical
Center plans,” he said.

Though the death rate of state newborns has
been lowered in recent years, statistics still show
more babies die in the first 28 days of life in
Mississippi than anywhere else in the nation. Of-
ficials say these deaths account for some two-
thirds of all state infants who die before they’re
a year old.

Most of the state newborns die of birth defects,
and many if caught in time can now be treated
and corrected, Dr. Brann points out. “Intensive
care for newborns is a new medical-nursing spe-
cialty. Goal of the Medical Center program is to
establish a model center,” he said, “where the
Mississippi newborn who comes into the world
sick can get the special help he needs and state
health professionals can learn advanced care tech-
niques.”

530

JOURNAL MSM A

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Index to Advertisers

Arch Laboratories 531

Becton, Dickinson and Company 516A, 516B

Breon Laboratories, Inc 8

Bristol Labs 16, 17, 525

Burroughs-Wellcome 484C

Campbell Soup Company 496A

The Carlton Corporation 15

Conal Pharm., Inc 496D

Dow Chemical Company 484B

Flint Laboratories 14

Geigy Pharmaceuticals 484A

Hill Crest Hospital 10

Hynson, Westcott and Dunning 3

Kay Surgical 531

Lederle Laboratories second cover, 4, 511, 520, 521

Leonard Wright Sanatorium 6

Eli Lilly and Company front cover, 18

Wm. S. Merrell Company 7

National Drug Company 480A, 480B, 508A, 508B

Wm. P. Poythress 484D

A. H. Robins Company 500A, 512A, 512B

Roche Laboratories 514, 515, fourth cover

Schering Corporation 14 A, 14B

G. D. Searle 496B, 496C

Stuart Pharmaceuticals 500B

Wyeth Laboratories 11, 12

Thomas Yates and Company third cover

53 1

SEPTEMBER 1970

Hospital utilization continues to grow, despite shorter patient
stays. But biggest growth factor is mounting number of outpatienl
visits which hit astonishing total of 163 million in 1969. Admis-
sion of inpatients rose to 30.7 million for year in all types of
hospitals. Total patients served was up from 121 million out-
patient visits and 28 million admissions in 19%B^ Source of figurs
is American Ktospital Association’s survey of 7,150 institutions.

Changes in HEW *3 Medicare regulations will impose new and severe
cost controls on hospitals. First will assure that Medicare pay-
ments aren*t based on inflated costs from sales of health facilitia
which will now have to value depreciable properties at lowest of
three figures : Actual cost, fair market value, or replacement cos

adjusted to depreciation. Hew provision also permits preadmission
diagnostic tesxs to help shorten patient stays.

Nixon administration welfare bill is running into stiff opposition
in Senate Finance Committee. Measure , with $1,600 annual family
guarantee, would increase welfare rolls by 128 per cent to 24 mill)
from present 10.4 million. In Mississippi, criteria would up roll;
much more, to 806,000 from present 211,000 or 282 per cent. If Men
caid benefits are also provided, the state would be faced with
$164 million yearly outlay, even with present bare bones program.

Sweden *s national health program, the late Walter Reuther*s dream :i
the United Slates, is in serious trouble. Costs run to 20 per cen-
nation* s entire tax revenue, yet 60,000 patients are on waiting li*;
for needed care. Sweden has 30 per cent fewer M.D. *s per capita tli
U.S., and hospital stays there are $0 per cent longer than in Amer::
institutions. Most other European national health programs are fsa
little better, and all are faced with high costs and poor services,

Physicians * claims under CHAMPUS (original military Medicare) progii
can be speeded up for payment by use of new claim form. Statements
for professional services should be submitted on DA Form 1863-2 dan
J une 1 , 1967. Older forms should he destroyed, typical tum-aroui;
time on CHAMPUS payments is five to 10 days when form is complete z\
correct. Supplies of newer form are free on request from state mec
cal association* s Department of Medical Care Plans.

Volume XI
Number 10
October 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.

Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary -T reasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. Cody Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

CONTENTS

original papers

Syringomyelia in

Mississippi 533 Ancel C. Tipton, Jr.,
M.D., and Armin F.
Haerer, M.D.

Case Report XIV of

Maternal Mortality Study 541 George J. Nassar, M.D.

Newborn Hematologic

Problems 543 Jeanette Pullen,

M.D., and Ross Smith,
M.D.

SPECIAL ARTICLE

Radiologic Seminar C:

Roentgen Diagnosis of
Anencephaly in Utero 554 Sam Levi, M.D.

EDITORIALS

Medical Care
Foundations; Private
Delivery That Works

An Economic Asset of
MSMA Membership

Like, Man, This Splits
From Webster

Antisubstitution Kill Is
a Crooked Straw

Profile of Our Children,
A Teenage Nation

Medicine’s Own System

Professional Liability
Help

An “In” Dictionary
Keep the M.D. Boss!
Astonishing Demography

557

559

561

561

565

THIS MONTH

The President Speaking 556 ‘Growing Pains’

Medical Organization 569 Beefed-Up Legislative

Program to Ask Aid of
All Members

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR OCTOBER 1970

J. B. Roerig
Markets Geopen

Geopen (disodium carbenicillin), a new semi-
synthetic penicillin which extends the range of
presently available penicillins against a variety of
difficult to treat gram-negative bacteria, has been
approved for marketing by the U. S. Food and
Drug Administration. Pfizer’s J. B. Roerig Divi-
sion announced the new drug would be avail-
able to physicians promptly.

Geopen is a product of Pfizer research and is
covered by U. S. Patent #3,142,673 which was
granted to Pfizer. The inventor is Donald C.
Hobbs, Ph.D., a scientist at the Pfizer Medical
Research Laboratories at Groton, Conn. Geopen
differs from the basic penicillin nucleus merely
by the addition of a carboxyl group.

Since the introduction of penicillin more than
a quarter of a century ago, physicians have found
that certain gram-negative pathogens which can
cause life-threatening infections are usually re-
sistant to penicillin therapy. Geopen is uniquely
effective against a variety of these gram-negative
bacteria, including Pseudomonas and Proteus or-
ganisms.

Geopen is also effective in vitro against the
usual gram-positive organisms susceptible to

penicillin, while extending the range of penicillin
activity to include a variety of gram-negative
bacteria. Susceptible organisms inlcude E. coli,
P. mirabilis, H. influenzae, Salmonella, Shigella
and Neisseria species. The outstanding character-
istic of Geopen is its unique effect upon Pseu-
domonas aeruginosa and indole-positive Proteus
species, which are usually resistant to other peni-
cillins.

Like other penicillins, Geopen is characterized
by a low level of toxicity even at high blood and
urinary levels. Ototoxicity (inner ear) or nephro-
toxicity (kidneys) either or both of which have,
until this time, been risks of therapy in many
serious gram-negative infections, do not occur
with Geopen. It is, however, contraindicated in
those patients who have demonstrated penicillin
allergy.

Geopen is not absorbed orally, but is admin-
istered intravenously and intramuscularly. Peak
blood levels are obtained in one to two hours
after I.M. injection, 15 minutes after I.V. injec-
tion. It is physically compatible with most com-
monly used intravenous fluids, and when recon-
stituted according to directions maintains its po-
tency for 24 hours at room temperature and for
72 hours if refrigerated.

It will be supplied in one gram and five gram
vials, to be reconstituted with sterile water.

‘rJMf Clio it

HOSPITAL

Hill Crest Foundation, Inc.

7000 5TH AVENUE SOUTH
Box 2896,

Birmingham, Alabama 35212
Phone: 205-836-7201

A patient centered
non-profit hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 45 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James K. Ward, M.D., F.A.P.A.

CLINICAL DIRECTOR:

Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL;

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

9^ C/test

HOSPITAL

BIRMINGHAM, ALABAMA

October 1970

ar Doctor:

3 new and expanded legislative program of state association is in
tion with recent meeting of Council on Legislation^ Asking every
aber to take an active part, the council will send weekly reports
all physicians, timed to arrive in Friday mail, during 1971 Regu-
c* Session. Program is positive, carrying out House of Delegates
1 Board of Trustees decisions (see lead news story this issue).

High on agenda is positive action on chiropractic cult.
annually a legislative threat to health of Mississippi.

But spine-punchers* fortunes are on wane with President * s
Task Force on Medicare and Medicaid asking Congress to
prevent payments to chiropractors under Medicaid.

i news for young physicians is odds-on chance that doctor draft
LI be resumed in 19/1 by Department of Defense. No M.D. *s have
m drafted this year, and only 246 were called up in 1969. But
?r y Plan enrollees, completing specialty training, are now down
per cent, and half of 15,000 medical officers now serving will
eligible for discharge during next 18 months.

aosexual aliens can be deported by U.S. Immigration and Natu-
lization Service under recent federal appellate court decision.
3e involved Canadian who pleaded guilty to homosexual acts under
lifomia law. Immigration officials entered deportation order
ich was upheld both in federal trial and appeals courts. Case
considered legal landmark in deportation precedents.

Linois State Medical Society has called for elimination of the
?d ^ coroner "from the state's new constitution. Testifying be-
?e the constitutional convention, ISMS officials said that the
Ly way to wipe out evils of present system is to get legal basis
? coroner out of constitution and force legislation to correct
fciquated laws. Change would not, however, require election of
X medical examiners in each of Illinois* 102 counties.

toh for mid-October mail for new combined billing statement of
sal, state, AMAt and AMfcAC dues with AMA-BKF gift reminder,

^service, set up at last annual session and implemented by Board
Trustees and local societies, will furnish one-check convenience
l tax-deduction documentation for association members.

Sincerely,

Rowland B. Kennedy
Executive Secretary

THE JOURNAL FOR OCTOBER 1970

1 0

Upjohn Releases
Oral Antibiotic

A new oral antibiotic that is reported highly
effective against infections of the upper and low-
er respiratory tract, skin, and other soft tissue
was made available to the medical profession by
The Upjohn Company today.

The semi-synthetic drug — Cleocin (clindamy-
cin)— is an outgrowth of years of research on its
parent compound, Lincocin (lincomycin). By
making changes in the chemical formula of Lin-
cocin, David I. Weisblat, Ph.D., vice president,
Pharmaceutical Research and Development for
The Upjohn Company said its scientists had de-
veloped a new antibiotic analog with more po-
tency, better oral absorption, and fewer side ef-
fects than the original.

Cleocin prevents the production of protein
substances which bacterial cells need for surviv-
al. The drug’s spectrum of in vitro activity in-
cludes strains of the most clinically significant
gram-positive bacteria and strains of a few spe-
cies of gram-negative bacteria. It is indicated
specifically for infections caused by streptococci,

pneumococci, and staphylococci. The drug is also
indicated for adjunctive therapy in dental infec-
tions.

In clinical tests with 1,416 patients, only 8.2
per cent reported side effects, usually mild gastro-
intestinal disturbances, investigators said. Skin
rash and urticaria reactions were infrequent.

The new antibiotic is 90 per cent absorbed in
the blood and is quickly and widely distributed
in body fluids and tissues, including bone, Up-
john researchers reported. Near peak concentra-
tions in the blood are reached in 45 minutes
following a 150-milligram dose after a 12-hour
fast. Peak levels are somewhat delayed when the
drug is given after a meal, but ingestion of food
does not appreciably modify the serum concen-
trations.

Laboratory tests of Cleocin HC1 showed that it
was 100 per cent effective against 124 strains of
pneumococci and 707 strains of streptococci,
with only four strains of resistant strep noted. It
was 96.3 per cent effective against 1,037 strains
of staphylococci, including 107 that were resist-
ant to erythromycin. These tests indicated that
most bacteria are slow in developing resistance
to the drug — an advantage in long-term treat-
ment— and that there was no cross-resistance with

LEONARD WRIGHT SANATORIUM

BYHALIA, MISSISSIPPI 3861 1 TELEPHONE A/C 601, 838-2162

LEONARD D. WRIGHT, SR., B.S., M.D., PSYCHIATRY

• Established in 1948. Specializing in the treatment of ALCO-
HOLISM and DRUG ADDICTIONS with a capacity limited
to insure individual treatment. Only voluntary admissions ac-
cepted.

• Located 25 miles S. E. of Memphis-Highway 78 on 20 acres
of beautifully landscaped grounds sufficiently removed to
provide restful surroundings.

• The Sanatorium is approved by The Commission on Hospital
Care in the State of Mississippi.

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

October 1970, Vol. XI, No. 10

Syringomyelia in Mississippi

ANCEL C. TIPTON, JR., M.D. and
ARMIN F. HAERER, M.D.

Jackson, Mississippi

Although intramedullary cavitation of the
spinal cord was recognized earlier, the term
“syringomyelia” was first coined by Oliver d’ An-
gers in 1837 to indicate cavities within the spinal
cord, regardless of etiology. Derivation of the
term arises from two Greek words: syrinx —
meaning pipe or fistula plus myelos — meaning
marrow. Syringobulbia is defined as the presence
of cavities in the medulla oblongata. It arises from
the two Greek words: syrinx plus bolbos — mean-
ing bulb.

The essential clinical features are slowly pro-
gressive atrophy of the muscles supplied by the
area of cervical spinal cord enlargement, disso-
ciated anesthesia in the involved cervical derma-
tomes, scoliosis, and “trophic” skin changes. If
the disease begins in the thoracic, lumbar, or
sacral spinal cord (much less common than cer-
vical syringomyelia), similar signs appear in cor-
responding segments producing a less typical clin-
ical picture. An apoplectic-like increase in all
symptoms and evidence of rapid extension of the
lesion to involve new structures may result from
hemorrhage into the syringomyelic cavity. This

From the Division of Neurology, University of Mis-
sissippi School of Medicine.

may be either spontaneous (due to anticoagula-
tion) or precipitated by trauma.

The clinical features of the neurological
disease syringomyelia are progressive atro-
phy of the muscles supplied by the area of
cervical spinal cord enlargement, dissociated
anesthesia in the involved cervical derma-
tomes, scoliosis, and “trophic” skin changes.
The authors discuss 16 patients with this dis-
ease and the therapy they received on the
neurological service at the University of Mis-
sissippi Medical Center.

Symptoms usually begin in the second or third
decade of life. At first the lesion will often be
limited to the entering pain and temperature fibers
giving rise to localized analgesia. Touch and deep
pressure sensibilities are preserved. This results
in painless burns, ulcers, and painless traumatic
injuries to the fingers which bring the patient to
medical examination. Subjective sensory symptoms
such as stiffness of the neck, deep boring pain,
crawling and tingling paresthesias, and severe

OCTOBER 1970

533

SYRINGOMYELIA / Tipton and Haerer

burning or sharp pains are common. Gradual
weakness of the hand results from atrophy of
the small intrinsic muscles of the hand and results
in the “claw-hand deformity.”

Symptoms are usually unilateral at the onset
but often become bilateral within a year. Vaso-
motor disturbances result in the “succulent hand”
which is moist, cold, swollen, and soft from edema
of the soft tissues rather than actual hypertrophy
of the tissues. Deep cyanosis develops when the
extremity is held in a dependent position. Later
the skin of the affected segments becomes hard
and thickened. The fingernails coarsen, frequent-
ly cease growing, and may actually fall out.

The history and neurological examination usu-
ally suggest the diagnosis of a deep intramedul-

Figure 1. Typical widening of cord shadow on
myelography in syringomyelia.

lary lesion of the spinal cord or the brain stem.
The best diagnostic aid is myelography since, in
addition to giving a reliable evaluation of the
pathologic process, it allows for analysis of cere-
brospinal fluid dynamics, cell abnormalities, and
chemical concentrations. This should be carried
out with the patient in the supine position in or-
der to adequately examine the foramen magnum
and hind-brain areas for possible cerebellar tonsil
herniation. Figure 1 shows the typical widening
of the cord shadow seen on myelography in cases
of syringomyelia. Fractional pneumoencephalog-
raphy is helpful in cases of bulbar lesions or those
associated with Arnold-Chiari malformation.

TABLE 1

DIFFERENTIAL DIAGNOSIS IN SYRINGOMYELIA

Intramedullary Tumor
Hematomyelia

Progressive Spinal-Muscular Atrophy

Raynaud's Disease

Leprosy

Congenital Insensitivity to Pain
Amyotrophic Lateral Sclerosis
Multiple Sclerosis
Central Cord Syndrome (Trauma)

Cervical Herniated Nucleus Pulposus

Cervical Spondylosis

Poliomyelitis

Brachial Plexitis

Carpal Tunnel Syndrome

Diabetic Abiotrophy

Syringobulbia

The differential diagnosis is thus concerned
with lesions of the central gray matter of the spi-
nal cord and lower brain stem. Table 1 lists some
of the conditions which are most apt to be con-
fused with syringomyelia. An intramedullary tu-
mor offers the greatest diagnostic difficulty. A tu-
mor, however, usually progresses much more rap-
idly and is less commonly associated with scoli-
osis. The development of disturbances of sensibil-
ity tends to rule out progressive spinal-muscular
atrophy. Raynaud’s disease is not accompanied
by as much analgesia or muscular atrophy. Com-
plete loss of pain sensibility without correspond-
ing loss of tactile sensation does not occur with
cervical rib syndromes. Congenital insensitivity
to painful stimuli is a total body phenomenon and
is not associated with the lesser degree of analgesia
seen in syringomyelia.

Some of the anomalies often associated with
syringomyelia are listed in Table 2. Secondary
syringomyelia may develop as a result of trauma,
chronic arachnoiditis, tumors, or from absorption
of blood into a hematomyelia lesion.

The consistency of the position of the cavities
in the upper cervical cord and medulla oblongata

534

JOURNAL MSM A

C 5

Shaded area :

Loss of pain and Temperature

Figure 2. Typical pattern of dissociated
spared) in a patient with syringomyelia.

with associated dilatation of the central canal
points to a developmental basis for syringomyelia.
Gardner’s1 theory of inadequate permeability of
the roof of the fourth ventricle occurring in the
critical sixth to eighth weeks of fetal life has
gained great popularity. The decreased outflow
of CSF from the fourth ventricle results in dilata-
tion of the central canal of the spinal cord and
subsequent syrinx formation because of transmis-
sion of the CSF pulsations which are maldirected
in these patients. A congenital communicating
hydrocephalus often also results and is found in
many cases of syringomyelia. Gardner thus advo-
cates exploration of the posterior fossa with visu-
alization of the roof of the fourth ventricle in
most cases of syringomyelia in order to be cer-
tain of normal egress of cerebrospinal fluid from

sensory loss (touch and posterior columns

the fourth ventricle, with decompression of the
cervicomedullary region where needed.

A review of the records at the University and
Veteran’s Administration Hospitals in Jackson,
Mississippi, with one additional patient supplied
by a local private neurologist, revealed 1 6 cases
of syringomyelia over a 10 year period. All were
males with ages ranging from five to 65 years.
There were 12 Negroes and four Caucasians.

Occupations included 1 1 heavy laborers, two
farmers, one bus driver, one office manager, and
one child. Three had a history of trauma in the
past, one of these with fractures of two cervical
vertebrae.

The most common presenting symptom was
that of weakness and numbness of the hand in 1 1
of the 16 patients. Four of these 11 exhibited

53 5

OCTOBER 1970

SYRINGOMYELIA / Tipton and Haerer

classical clawhand deformities. Three had re-
ceived severe burns of the involved fingers and
hands. Two patients presented with symptoms of
cramps and “twitches” in the involved muscula-
ture and difficulty with walking. One presented
with dystonic posturing of the hand and “locking”
of the second and third lingers together. He also
complained of inability to do fine movements of
the fingers involved, a sensation of “coldness” in
the hand, and “jerking” of the involved arm on
coughing, sneezing, or when frightened. Three
other patients complained of leg weakness and
difficulty in walking, and two had significant in-
fections of the involved extremities. One patient
had involvement of bladder function with recur-
rent infections and a large residual urine volume.

Many different types of sensory deficits were
found, ranging from a shawl-like distribution defi-
cit to a definite sensory level for all modalities in
a patient having a complete block. Figure 2 shows
a typical sensory pattern in one of these patients
with syringomyelia. Deep tendon reflexes were
usually decreased or absent at the level of the
lesion, and increased or pathologic reflexes were
found below the lesion. One patient had Horner’s
syndrome.

Myelograms were diagnostic in eight patients
revealing the classical widening of the cord. Three
of these eight patients had a normal Quecken-
stedt response, two had a completely blocked re-
sponse, and two had a partially blocked response.
Two patients had fractional pneumoencephalo-
grams both of which showed non-filling of the ven-
tricular system. Plain x-rays showed definite
platybasia in 62 per cent of the patients and
questionable platybasia in all others; there was
scoliosis in 25 per cent, and definite widening of
the inter-peduncular spaces on cervical spine
films in 16 per cent. Occipitalization of the atlas,
either partial or complete, was present in 78 per
cent of the patients.

TABLE 2

ASSOCIATED ANOMALIES IN SYRINGOMYELIA

Platybasia

Arnold-Chiari Malformation
Klippel-Feil Deformity
Cervical Ribs
Spina Bifida

Lumbar punctures were performed on all pa-
tients and revealed normal cell counts and chem-
istries except in one patient with a complete block
and an elevated protein. Blood and cerebrospinal
fluid VDRL tests were non-reactive in all pa-

tients. Electromyograms of the involved muscula-
ture confirmed lower motor neuron disease in
four patients.

Seven patients were treated surgically. Two
posterior fossa craniotomies, four cervical lam-
inectomies, and one laminectomy from L3 to Ti0
were done. Insertion of a wick into the cyst
cavity was done twice. One patient received a
two month course of ACTH therapy without im-
provement. The remaining eight patients declined
operative intervention and were managed with re-
habilitative measures, social adjustments, and pro-
phylactic therapy. One patient at operation was
definitely noted to have a membrane obstructing
the foramen of Magendie and a communication
was demonstrated between the syrinx cavity, the
central canal of the cord, and the obex of the
fourth ventricle — thus supporting the theory of
Gardner. Two were thought to be cases of sec-
ondary syringomyelia caused by trauma to the
neck. One was rendered quadriplegic after a div-
ing injury some 20 years prior to admission and
from which he gradually recovered over a six
month period of time.

FOLLOWUP FINDINGS

Four patients could not be followed up. The
other 12 were followed for periods ranging from
two to 18 years, with an average followup time of
6.9 years. At the end of the followup period,
one had died of an unrelated disease, three were
working, six were ambulatory but not working,
and two were not ambulatory. The disease
seemed to arrest in several patients postoperative-
ly, but the ultimate outcome, due to the normally
slow progression in many patients, is not entirely
clear from the results of this series to date.

The majority of the cases had far advanced
symptoms and neurological findings at the time of
initial neurological evaluation. It should be
stressed that earlier referral of these cases would
hopefully result in less permanent neurologic defi-
cit and thus a better rehabilitative prognosis.

It is interesting to note that all were males, 12
were Negroes, and that the majority were heavy
laborers. One therefore wonders if this condition
might not be more prevalent under these condi-
tions in Mississippi.

Bowman and Iivanainen2 reported a prognos-
tic study of 55 patients with syringomyelia with
an observation time varying between two and 45
years. Most patients exhibited slow progression of
neurological impairment and in 27 patients a
stationary neurological condition had lasted for
greater than 10 years. Twenty-two of the pa-
tients were still working daily while 22 were

536

JOURNAL MSM A

pensioned due to unfitness for work. Eleven pa-
tients had expired. The prognosis in 22 cases
treated with roentgen therapy was the same as in
23 untreated cases. They point out, that with the
aid of rehabilitation procedures, social adjust-
ments, and prophylactic therapy, the working
capacity and life expectancy of these patients can
be maintained for longer periods of time.

Love and Olafsoffi reported their results with
the use of tantalum-wire to maintain a fistula be-
tween the syrinx cavity and the spinal subarach-
noid space. They had 48 patients with a follow-
up of greater than two years. Their experience
showed that patients with symptoms of long dura-
tion or with rapidly progressive deficits respond-
ed less well to this type of surgical intervention
than those with symptoms of short duration. In
recent years the surgical treatment recommended
by Gardner mentioned above has become the stan-
dard and most rewarding approach with arrest of
progression in many instances.

SUMMARY

Sixteen patients with syringomyelia are pre-
sented, seven of which had surgical intervention.

Two were thought to be cases of secondary syrin-
gomyelia. One of the surgically treated patients
supported the theory of Gardner. Presenting neu-
rological symptoms and signs are discussed. A
brief review of the literature points out pertinent
findings in regard to prognosis, modes of treat-
ment, and etiology of this condition. The pos-
sibility of an increased incidence of this condition
in the Negro male heavy laborer in Mississippi is
suggested. It is hoped that earlier referral of sug-
gestive cases will result in less permanent neuro-
logical deficits and thus better rehabilitation of
individuals with syringomyelia. ***

2500 N. State Street (39216)
Supported in part by USPHS training grant NBO 5215.

REFERENCES

1. Gardner, W. James: Embryologic Origin of Spinal
Malformations, Acta Radiol. 5:1013-1023, 1966.

2. Bowman. K., and Iivanainen, M.: Prognosis of Syrin-
gomyelia, Acta Neurol. Scandinav. 43:61-68, 1967.

3. Love, J. G., and Olafson, R. A.: Syringomyelia: A
Look at Surgical Therapy, J. Neurosurgery 24:714-
718, 1966.

VISITING PRIVILEGES

The case worker at the welfare office was interviewing a mother
who asked for aid for her 13 children. “But I don’t understand.
You say your husband left you 10 years ago, yet eight of your
children are under 10 years of age.”

“Oh, I can explain that,” beamed the applicant. “He comes
back now and then to apologize.”

OCTOBER 1970

537

When irritable colon feels like this

i

i

The blowfish, a small spec
of fish, reacts to stress or
fright by puffing itself up i
air. After about a dozen
noisy gulps the belly is ball
shaped and hard. When
replaced in the water the
quickly expelled, and
the fish sinks to the botton

. in the presence of spasm or hypermotility,
gas distension and discomfort, KINESED
provides more complete relief :

□ belladonna alkaloids— for the hyper-
active bowel □ simethicone — for ac-
companying distension and pain due to
gas □ phenobarbital— for associated
anxiety and tension

Composition: Each chewable, fruit-flavored, scored tab-
let contains: 16 mg. phenobarbital (warning: may be
habit-forming); 0.1 mg. hyoscyamine sulfate; 0.02 mg.
atropine sulfate; 0.007 mg. scopolamine hydrobromide;
40 mg. simethicone.

Contraindications: Hypersensitivity to barbiturates or

belladonna alkaloids, glaucoma, advanced renal or he-
patic disease.

Precautions: Administer with caution to patients with
incipient glaucoma, bladder neck obstruction or uri-
nary bladder atony. Prolonged use of barbiturates may
be habit-forming.

Side effects: Blurred vision, dry mouth, dysuria, and
other atropine-like side effects may occur at high doses,
but are only rarely noted at recommended dosages.
Dosage: Adults: One or two tablets three or four times
daily. Dosage can be adjusted depending on diagnosis
and severity of symptoms. Children 2 to 12 years: One
half or one tablet three or four times daily. Tablets may
be chewed or swallowed with liquids.

STUART PHARMACEUTICALS I Pasadena, California 91109 I Division of ATLAS CHEMICAL INDUSTRIES, INC.

(from the Greek kinetikos,
to move,

and the Latin sedatus,
to calm)

KINESES

antispasmodic/sedative/antiflatulent

Counsel to Authors

The Journal welcomes manuscripts
which should be submitted to the Editors
at 735 Riverside Drive, Jackson, Miss.
39216, in original and at least one dupli-
cate copy. They must be typewritten dou-
bled spaced on 8V2 by 11 -inch white bond
paper with a standard typewriter.

The author is responsible for all state-
ments made in his work, including changes
made by the manuscript editor. Manuscripts
are received with the understanding that
they are not under simultaneous considera-
tion by any other publication and have not
been previously published. All manuscripts
will be acknowledged, and while those re-
jected are generally returned to the author,
the Journal is not responsible in event of
loss. Manuscripts accepted for publication
become the property of the Journal and
are copyrighted by the association when
published. They may not be published else-
where without written release and permis-
sion from both the Journal and the author.

All copy must be double spaced, in-
cluding legends, footnotes, and references.
Generous margins at the top, bottom, and
on both sides of the page should be allowed.
Each page after the title page should be
consecutively numbered and carry a run-
ning head identifying the paper and author.

Titles should be short, specific, and clear.
Ordinarily, a title should not exceed 80
characters, including punctuation.

References should be limited to a maxi-
mum of 10, but when justified to the Edi-
tors, additional references will be considered
for publication. Each will be critically ex-
amined, and only valid, primary references
will be published. Textbooks, personal com-
munications, and unpublished data may
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5 40

JOURNAL MSM A

Case Report XIV
Of Maternal Mortality Study

GEORGE J. NASSAR, M.D.
Greenwood, Mississippi

The following case report represents death
from hemorrhage and shock, due to acute, post-
partum inversion of the uterus.

CASE NO. 576-99999-68

A 25-year-old mother of four living children
was pronounced dead, shortly after delivering her
fifth normal child.

This patient, gravida VI, had an apparently
normal antepartal course. She presumably had an
adequate, gynecoid pelvis, since she had de-
livered five term infants, at home without diffi-
culty. It was assumed by the physician, who saw
her just prior to death, that she had been seen
once at the prenatal clinic of the Washington
County Health Department.

The patient was delivered at her home, at-
tended by a midwife, on Nov. 23, 1968. The
onset of labor was spontaneous. She delivered,
spontaneously, a live boy who weighed six pounds
eight ounces. The duration of pregnancy could
not be ascertained, but was presumed to be full
term. The duration of labor was not reported.
The midwife stated that the patient began to
bleed profusely during labor and immediately fol-
lowing delivery of the child. The duration of
bleeding was not recorded.

With the onset of the third stage of labor there
seemed to be a complete absence of data except
for the knowledge that no consultation was sought,
no effort was made to transport the patient to a
hospital and no blood was given. There is also no
knowledge as to placental delivery and whether

Obstetrics and gynecology member, Committee on

Maternal and Child Care.

the placenta was intact. A physician was sum-
moned, who diagnosed the presence of an acute,
puerperal uterine inversion in a dying woman.
The patient expired on Nov. 23, 1968.

The patient in this case report is a 25-
year-old Negro female, gravida VI, who died
shortly after delivering her fifth normal child.
She was diagnosed as having an acute, pu-
erperal uterine inversion. The committee
discusses the case, rating it as avoidable if
a physician had been in attendance when the
uterus inverted.

This case was reviewed anonymously in the
usual manner, by a member of the MSMA Com-
mittee on Maternal and Child Care and discussed
at a regular, quarterly meeting of the committee.

The adequacy of the information received was
rated at 1 on an ascending scale of 1 to 5. The
committee expressed regret that the physician was
called in too late to save the mother’s life. This
death was classified as an avoidable, obstetric
death, due to hemorrhage and shock resulting
from acute, postpartum inversion of the uterus.
The committee members also felt that midwives
should be constantly mindful of the absolute ne-
cessity of referring patients promptly at the earli-
est sign of any deviation from normal of a preg-
nancy or delivery under their care to a physician
and the nearest hospital. Fortunately, most ob-
stetrical deaths can be prevented and it behooves
one to seek out early signs of impending compli-

OCTOBER 1970

541

cations and early consultation and institution of
treatment.

The author would like to review, briefly, some
of the pertinent facts relating to this complication.

1. Occurrence

Ten cases were reported at Emanuel Hospital
in 44,723 deliveries from 1950 through 1959. 1
The proportion of inversions in the Negro and
White race is essentially equal.2 McCullogh2 es-
timated that the average age at which inversion
occurs is 27. Torpin2 stated that more than 50
per cent of reported cases were in the primipara.
The majority of the cases reported occurred fol-
lowing term pregnancy.3 4

2. Etiology

A. Predisposing factors:

(a) Laxity or thinness of the uterine wall at
the placental site.

(b) Uterine atony, following exhaustive labor
or uterine muscular incoordination, which may be
precipitated by the administration of an oxy-
tocic agent.

(c) Overdistension of the uterus such as in
multiple pregnancy or hydramnios.

(d) Fundal implantation of the placenta, more
common in the primipara, also varying degrees
of accreta.

B. Precipitating factors:

(a) Traction on the cord.

(b) Excessive fundal pressure.

(c) Manual removal of the placenta, by incom-
plete removal or suction affect resulting from rap-
id withdrawal of the operator’s hand from the
uterus.

(d) Short cord.

(e) Sudden changes in intraabdominal pres-
sure, such as sneezing, coughing, vomiting or at-
tempting to sit up.

The first three precipitating factors, listed
above, account for over 50 per cent of cases of
uterine inversion and constitute mismanagement
of the third stage of labor and are the ones over
which one has the most control; so its dangers are
worth reiterating.

3. Diagnosis

A. Complete inversion is relatively self-diag-
nostic.

B. Incomplete inversion:

(a) Cupping or dimpling of the fundus on ab-
dominal palpation.

(b) Hemorrhage.

(c) Shock out of proportion to blood loss.

An immediate thorough examination of the en-
tire genital tract will quickly establish the diag-
nosis. Such an examination should be performed
routinely after every delivery.

4. Treatment

This consists of early diagnosis and prompt re-
placement of the uterus, once shock measures are
instituted. It should be emphasized that as long
as the “inflicting agent” of shock is still in action
and will remain so unless the uterus is replaced
immediately, the patient’s recovery is imperiled.
If the placenta is still attached, the inversion must
be reduced before attempting to deliver the pla-
centa.

It must be remembered that deep anesthesia
should be employed to relax the cervix. Occasion-
ally the injection of seven drops of adrenalin into
the cervical ring may induce cervical relaxation
and then cupping the fingers over the inverted
portion of the uterus with upward push will re-
place the uterus.

Subacute and chronic cases of uterine inver-
sion may require surgical intervention for defini-
tive treatment.

SUMMARY

A maternal death due to postpartum inver-
sion of the uterus is reported. This condition can
be easily diagnosed and treated. In over 50 per
cent of cases it can be prevented by proper man-
agement of the third stage of labor and in the
minority group of reported cases it may be spon-
taneous and can “happen to anyone.”

A complete genital examination after each de-
livery is strongly recommended as a routine mea-
sure to rule out the presence of such a postpar-
tum complication.

405 River Road (38930)
REFERENCES

1. Eastman, N. J.: Williams Obstetrics, ed. 11. New

York, Appleton-Century-Crofts, 1956.

2. Torpin, R.: J. Med. A. Georgia 36:63, 1947.

3. McCullogh, W. McK. H. : J. Obst. & Gynaec., Brit.

Empire 32:280, 1925.

4. Holmes, R. W. : Obstetrics 1:297, 1899.

JOURNAL MSMA

542

Seminar on Care of the Newborn — IV

Newborn Hematologic Problems

JEANETTE PULLEN, M.D., and
ROSS SMITH, M.D.
Jackson, Mississippi

In evaluating the newborn’s hematologic status,
one must take into account certain influences
which need be considered only in this age group.
The mother’s hematological status may influence
that of the fetus. Since fetal blood formation and
hemostatic mechanisms mature progressively dur-
ing intrauterine life, the degree of maturity at
birth influences the newborn's hematological
status.

Perinatal events predisposing to maternal and/
or fetal blood loss must be taken into account.
Finally, one must remember that the normal new-
born’s blood counts change progressively over the
first few weeks of life from those best suited to
intrauterine life to those best suited to extrauter-
ine life.

Anemia and hemorrhage are the two principal
hematological problems which are encountered
commonly in the neonatal period.

To identify anemia in the newborn, one must
be familiar with normal values for hemoglobin
and hematocrit in this age group. Unfortunately
in the newborn, normal values have been difficult
to delineate, because of the influence of several
factors. The site of sampling affects results,
since hemoglobin concentration is about 2.5 to
3.5 gm./lOO ml. higher in capillary (heel stick)
samples than in simultaneously obtained venous
samples.1- 2 (The higher capillary hemoglo-
bin is apparently due to sluggish circulation in
peripheral vessels during the first few days of life,
with resultant transudation of plasma from the
small vessels.3) Early versus delayed clamping of
the cord at delivery influences the total red cell
volume in the newborn.4

From the Department of Pediatrics, University of Mis-
sissippi School of Medicine. Jackson, Miss.

In all infants during the early hours after
birth, an increase in hemoglobin concentration
occurs, usually in the range of about 3 gm./lOO
ml. This is probably due to a decrease in plasma
volume during early extrauterine existence.4

Influences pertinent to the evaluation of
the newborn’s hematologic status are dis-
cussed. Normal values, the anemias, bleed-
ing, thrombocytopenia, hemophilia, and
a range of conditions are examined, dis-
cussed, and framed with practical guides. Vi-
tamin K deficiency and transfusion axioms
are also considered. The authors present a
study of sufficient depth to afford compre-
hensive consideration of the subject area.

In spite of these variables, fairly reliable norms
have been established. Normal cord blood hemo-
globin is in the range of 16.5 to 17.1 gm./lOO ml.,
with simultaneous capillary hemoglobin determi-
nations of about 19.8 gm./lOO ml. Normal cord
blood hematocrit values are approximately 51%
to 56%. In general, a newborn is considered ane-
mic if the cord blood (or other venous sample)
hemoglobin is less than 14 gm.,/100 ml., or if the
capillary hemoglobin is below 15 gm./lOO ml.
The mean hemoglobin values for premature in-
fants are slightly lower, with a mean hemoglobin
at 38 weeks’ gestation of 15.2 gm./lOO ml., at
34 weeks of 15 gm./lOO ml., and at 28 weeks of
14.5 gm./lOO ml.3 Table 1 records mean values
for peripheral blood counts obtained in a large
series of normal newborns.

OCTOBER 1970

543

Newborn Hematology / Pullen and Smith

During the first week of life, there is normally
no decrease in hemoglobin values. Thereafter,
the hemoglobin and hematocrit fall steadily be-
cause of minimal marrow erythropoiesis and de-
creased red cell survival. The term infant reaches
a minimum hemoglobin level (around 9 to 10
gm./lOO ml.) at approximately three months of
age. In the premature, the fall occurs more rapid-
ly and the low point (7.5 to 9.0 gm./lOO ml.) is
reached at about six to eight weeks of age. In
general, the smallest infants exhibit the most
rapid fall in hemoglobin and develop the most
marked degree of anemia.

When the above described hemoglobin de-
cline reaches frankly anemic levels (the so-
called physiologic anemia), the bone marrow is
stimulated to reinstitute active erythropoiesis, and
the minimal anemia is gradually corrected. In the
premature infant, the actively resumed erythro-
poiesis may not be sufficient to keep up with
the rapidly growing baby’s blood volume and the
“physiologic” anemia may persist longer than in
the term infant.

UTILIZATION OF IRON

At the time active erythropoiesis resumes, iron
is actively utilized in the formation of new hemo-
globin. In the term infant, the iron derived from
the breakdown of the initial large red cell mass
and that derived from tissue iron stores supplies
adequate iron for red cell production, provided
dietary intake is adequate. In the premature,
however, tissue iron stores are often inadequate,
since the majority of fetal iron is acquired trans-
placentally during the last trimester of pregnancy.
Therefore, supplementary iron should be admin-
istered to the premature infant, beginning at
about the time active red cell production begins.

As a general rule, iron supplementation is be-
gun at four to six weeks of age for those infants

remaining in the premature nursery, or at the
time of discharge if this is prior to one month of
age. For prophylaxis, 8 to 15 mg. of elemental
iron per day is suggested. For treatment of overt
iron deficiency anemia, 5 to 7 mg./kg. of ele-
mental iron per day is recommended.

HEMOLYSIS

Anemia in the neonatal period usually re-
sults from one of two major causes: hemolysis or
hemorrhage.

When hemolysis of fetal cells occurs in utero,
it is usually caused by maternal-fetal red cell Rh
antigen incompatibility. If in utero hemolysis is
extensive, the infant may be born severely ane-
mic.

Hemolysis occurring in the first few days of
extrauterine life is more common and is evidenced
by the following: (1) Increased reticulocyte count
and increased numbers of nucleated red cells,
above normal values shown in Table 1, (2) ac-
cumulation of red cell break-down products, prin-
cipally bilirubin, with a predominance of in-
direct reacting bilirubin, and (3) falling hemo-
globin during the first week of life without evi-
dence of hemorrhage.

The leading cause of hemolysis in the new-
born is maternal iso-sensitization against fetal red
cells.5 Both Rh and ABO incompatibilities can
cause hemolysis. Because the diagnosis and treat-
ment of this type of hemolytic disease of the new-
born constitutes a topic in itself, the authors
have decided to devote a separate article in this
series to the diagnosis and management of isoim-
mune hemolytic disease in the newborn. Other
types of hemolytic anemias in the newborn period
may be divided into acquired and hereditary he-
molytic anemias.

Neonatally acquired hemolytic anemias related
to infections are seen commonly in pediatric prac-
tice. In the newborn, severe infections (particu-

TABLE 1

MEAN NORMAL VALUES IN THE FULL

TERM

INFANT*

Cord

Value

Blood

Day 1

Day 3

Day 7

Day 14

HGB (gms/100 ml.) .

16.8

18.4

17.8

17.0

16.8

Hematocrit (%)

53.0

58.0

55.0

54.0

52.0

Reticulocytes (% ) . . .

3-7

3-7

1-3

0-1

0-1

Nuc. RBC/100 WBC

7-8

1-5

0-2

0

0

Platelets/cu.mm.

290,000

192,000

213,000

248,000

252,000

WBC’s/cu.mm

18,100

22,000

11,000

12,200

11,400

* From combined data of Oski and Naiman, 1966, and Kato, 1935.

544

JOURNAL MSM A

TABLE 2

SOME OF THE MORE COMMONLY USED AGENTS
REPORTED TO PRODUCE HEMOLYSIS IN
PATIENTS WITH G-6-PD DEFICIENCY

ANTIMALARIALS
Quinacrine (Atabrine)

Quinine

ANTIPYRETICS AND ANALGESICS
Acetylsalicylic Acid (ASA)

Acetophenetidin (Phenacetin)
p-Aminosalicyclic Acid (PAS)

Aminopyrine

INFECTIONS

Respiratory Viruses
Infectious Hepatitis
Infectious Mononucleosis
Bacterial Pneumonias

NITROFURANS

Nitrofurantoin (Furadantin)

Furazolidone (Furoxone)

Nitrofurazone (Furacin)

SULFONAMIDES
Sulfanilamide
Sulfacetamide (Sulamyd)

Sulfamethoxypyridine (Kynex, Midicel)
Salicylazosulfapyridine (Azulfidine)

Sulfisoxazole (Gantrisin)

Sulfapyridine

MISCELLANEOUS
Acetylphenhydrazine
Chloramphenicol
Chloroquine
Dimercaprol (BAL)

Fava Beans
Methylene Blue
Naphthalene ("Moth Balls”)

Nalidixic Acid (Negram)

Orinase

Phenylhydrazine

Probenecid

Quinidine

Vitamin K (Large doses of water soluble analogues)

larly sepsis) are likely to be accompanied by he-
molysis. Bacterial, viral (cytomegalic inclusion
disease, rubella syndrome), protozoan (toxoplas-
mosis) and spirochetal (syphilitic) infections may
cause hemolysis. Hemolytic anemias may some-
times be precipitated by the administration of cer-
tain drugs to the mother prior to delivery or to
the neonate after delivery.

Hereditary hemolytic anemias involve an in-
trinsic defect in the infant’s red cells, which
causes shortened red cell survival.

Morphologic abnormalities of the red cell can
often be suspected from routine examination of

the newborn's peripheral blood smear. Congeni-
tal spherocytosis may, on occasion, present with
extensive hemolysis in the nursery, sometimes re-
quiring exchange transfusion. Spherocytes may
or may not be numerous on the peripheral smear
at this early age. (One should keep in mind that
some spherocytes may be seen in any hemolytic
anemia, and particularly in ABO incompatibili-
ties.) Since congenital spherocytosis is inherited
in a dominant fashion, the diagnosis can often
be confirmed by family studies. Congenital ovalo-
cytosis (elliptocytosis) may occasionally cause
significant hemolysis in the neonatal period.

HEMOGLOBINOPATHIES

Hemoglobinopathies are not usually manifested
as hemolytic disease during the neonatal period,
because of the predominance of fetal hemoglobin
during this time. However, a positive test for
sickling may sometimes be obtained during the
newborn period.

Inherited enzymatic deficiencies of the red
cells may cause hemolysis in the nursery. The
most common red cell enzymatic deficiency is that
of glucose-6-phosphate dehydrogenase (G-6-PD),
fairly common in Negro infants. Drugs known to
precipitate hemolysis in G-6-PD deficient pa-
tients (Table 2) may cause neonatal hemoly-
sis when administered to the mother near term.
Apparently newborn infants with G-6-PD defi-
cient red cells may sometimes demonstrate spon-
taneous hemolysis without drug provocation.
Other congenital red cell enzymatic deficiencies
occur but are quite rare.

HEMOLYTIC ANEMIA

Even in the normal newborn, many of the
red cell enzymes are immature, causing hemolysis
to occur more readily than in the older child or
adult.3 Almost all types of neonatal hemolytic
anemias, if severe, may result in hyperbilirubine-
mia of sufficient degree to require exchange trans-
fusion to prevent kernicterus. Table 3 provides a
working diagram for the diagnosis of the etiology
of a hemolytic anemia in the newborn period.

Fetal bleeding, before or during delivery, ac-
counts for only 5 to 10 per cent of cases of anemia
in the newborn period. When severe perinatal
bleeding does occur, however, the mortality may
exceed 50 percent.6 Rapid loss of a relatively
small volume (30 to 50 ml.) of blood in a new-
born is sufficient to produce shock.7 So small a
volume may go undetected during delivery or be
misinterpreted as maternal bleeding.

The fetus can bleed from six different path-
ways:

(1) Bleeding from the umbilical cord. A nor-

OCTOBER 1970

545

Newborn Hematology / Pullen and Smith

inal cord very rarely tears during delivery but
when aberrant cord vessels or velamentous in-
sertion of the cord are present, rupture of um-
bilical vessels may occur.

(2) Spontaneous bleeding from the placenta
at delivery. Though most maternal vaginal bleed-
ing represents bleeding from the maternal side of
the placenta, placenta previa, abruptio placentae
and vasa previa may cause fetal as well as ma-
ternal bleeding.

(3) Incision into the placenta during cesarean
section. An anteriorly placed placenta may be in-
cised during cesarean section, resulting in signifi-
cant blood loss from the fetus.

(4) Fetomatemal hemorrhage. Passage of fetal
red cells into the maternal circulation occurs com-
monly during pregnancy. The amount of fetoma-
ternal hemorrhage is usually less than 1 ml., but
occasionally is of sufficient degree to cause severe
anemia in the newborn. The majority of fetoma-
ternal hemorrhages occur during delivery, though
rarely a chronic leakage of red cells from fetus
to mother can occur during pregnancy.

(5) Twin to twin hemorrhage. When twins
share a monochorionic placenta, blood from one
twin may be diverted to the other twin by way of
intercommunications between the vessels of the
placenta, resulting in anemia in one twin and
plethora in the other. A twin to twin transfusion
should be suspected if a hemoglobin difference of
5 gm./lOO ml. or greater is evident in the twins
at delivery.

(6) Internal hemorrhage. Breech deliveries
may be associated with hemorrhage into the liver,
kidney, spleen or retroperitoneal area. Traumatic
or precipitous deliveries may cause subdural or
subarachnoid hemorrhage of sufficient magnitude
to result in anemia. Even cephalohematomas may
be of sufficient size to produce anemia.

The treatment of the newborn who is anemic
at birth depends on the degree of anemia and
the acuteness of the blood loss. If the hemorrhage
has been chronic and of minimal degree during
intrauterine life, the baby may be anemic but in
no acute distress. In this case, transfusion, if
necessary at all, can best be given in the form of
packed cells. If the bleeding has been severe and
prolonged in utero, elevated venous pressure or
evidence of edema in the infant may require that
packed cells be administered by means of a par-
tial exchange transfusion.

If extensive hemorrhage occurred shortly before
or during delivery, the newborn will exhibit ex-
treme pallor and shock at birth. In such a baby,
the hemoglobin value may not immediately re-
flect the recent blood loss. This infant requires
immediate transfusion with whole blood.

BLEEDING AFTER DELIVERY

Excessive bleeding in an infant in the first days
of life suggests the possibility of an abnormal
hemostatic mechanism in the baby. Hemostatic
defects in the neonate may be acquired and tran-
sient, or inherited and lifelong. The principal
causes of ineffective hemostasis in the newborn
are: thrombocytopenia, vitamin K deficiency, liv-

TABLE 3

DIFFERENTIAL DIAGNOSIS OF COMMON HEMOLYTIC ANEMIAS IN THE NEWBORN

Spirochetal
Syphilis
Protozoan
Toxoplasmosis

Aniline

Nitrobenzene

Naphthalene

Phenylhydrazine

Others

5 46

JOURNAL MSMA

TABLE 4

DIAGNOSTIC APPROACH TO THE THROMBOCYTOPENIC NEWBORN*

MOTHER

1.

History previous bleeding (ITP?) , drugs, illness,
infants with purpura, rubella in T^

Test for syphilis

Platelet count

1. Maternal ITP, S.L.E.

2. Drug purpura

3. Inherited thrombocytopenia

Examine Infant

a. Normal

1) Isoimmune purpura

2) Thiazides

3) Inherited thrombocytopenia

4) Early congenital aplastic

anemia

T

b. Hepatosplenomegaly

1) Infections

bacterial sepsis

congenital syphilis

disseminated herpes

cytomegalic inclusion
disease

c. Congenital anomalies

1) Giant hemangioma

2) Rubella syndrome

3) Absent radii

4) Fanconi's anemia

congenital toxoplasmosis
2) Congenital leukemia

* From Oski and Naiman. 1966.

er immaturity, hemophilia and intravascular co-
agulation.

Petechial skin lesions, especially when widely
distributed, suggest the possibility of thrombocy-
topenia. A peripheral blood smear should be
examined to determine if the platelets appear de-
creased on smear. If one sees less than five plate-
lets in most oil immersion fields, thrombocyto-
penia is likely. This should be confirmed with a
phase platelet count. If the platelet count is less
than 100,000/MM3, significant thrombocyto-
penia exists. Overt bleeding usually occurs only
if the platelet count is less than 30,000/ MM3.

In a baby with thrombocytopenia, but with no
other coagulation defect, bleeding is usually con-
fined to skin petechiae and ecchymoses and to

mucous membrane bleeding. However, there is
always the possibility of an occasional thrombo-
cytopenic baby’s bleeding into internal viscera.
Though intracranial hemorrhage is rare in neo-
natal thrombocytopenia, it may occasionally oc-
cur. It is most to be feared in the immediate
postdelivery period in the presence of general,
severe thrombocytopenic bleeding.

Normal values for phase platelet counts in
term infants during the first week of life do not
differ significantly from those of older children
and adults (Table 1). Routine determinations of
platelet counts in premature infants with no evi-
dence of bleeding have been done in only a few
nurseries. However, there is evidence that some
premature babies may have “physiologically” lowy

OCTOBER 1970

547

His makeup is unique by tradition.

*

His ulcer treatment is unique
by tradition, too.

.

In the world of
entertainment, a clown’s
makeup remains the
exclusive property of its
originator. Time has
established that tradition.
In the treatment of ulcers
and other gastrointestinal
complaints, time has
established Pro-Banthine
as a tradition too.

Few drugs can boast a
longer successful run.
Introduced 17 years ago,
this drug is a veteran
gastrointestinal performer.

Pro-Banthine stars in the
treatment of peptic ulcer,
functional gastrointestinal
disturbances, ulcerative
colitis, hypertrophic gastritis,
pylorospasm, acute and
chronic pancreatitis,
diverticulitis, biliary
dyskinesia, hyperhidrosis,
ileostomies, and colonic,

ureteral or urinary bladder
spasm. Its fame. as an
anticholinergic is worldwide.
' When you want a
performer you can count on
. . . remember Pro-Banthine.
Tradition does.

, 1

i ii

Research in the service of medicine.

G.D.Searle&Co., Chicago, III. 60680

Pro-Banthine

(propantheline bromide)

the traditional ulcer treatment

Pro-Banthine 15 mg.

propantheline bromide

Pro-Banthine 15 mg.

propantheline bromide
with

Dartal 5 mg.
thiopropazate
dihydrochloride

Pro-Banthine 15 mg.

propantheline bromide
with

Phenobarbital 15 mg.
warning:

may be habit forming

Pro-Banthine P.A. 30 mg.

propantheline bromide
in time-release form

Pro-Banthine 71/2 mg.
propantheline bromide
Half Strength

Pro’Banthine

(propantheline bromide)

Indications: Peptic ulcer, gastroenteritis,
pylorospasm, biliary dyskinesia, functional
hypermotility and irritable colon.
Contraindications: Glaucoma, severe cardiac
disease.

Precautions: Since varying degrees of urinary
hesitancy may occur in elderly men with pros-
tatic hypertrophy, this should be watched for
in such patients until they have gained some
experience with the drug. Although never re-
ported, theoretically a curare-like action may
occur with possible loss of voluntary muscle
control. Such patients should receive prompt
and continuing artificial respiration until the
drug effect has been exhausted.

Side Effects: The more common side effects,
in order of incidence, are xerostomia, mydri-
asis, hesitancy of urination and gastric fullness.
Dosage: The maximal tolerated dosage is usu-
ally the most effective. For most adult patients
this will be four to six 15-mg. tablets daily in
divided doses. In severe conditions as many
as two tablets four to six times daily may be
required. Pro-Banthine is supplied as tablets
of 15 mg., as prolonged-acting tablets of 30
mg. and, for parenteral use, as serum-type vials
of 30 mg. The parenteral dose should be ad-
justed to the patient’s requirement and may
be up to 30 mg. or more every six hours, intra-
muscularly or intravenously.
Pro-Banthine® 15 mg.

(propantheline bromide)
with

Dartal® 5 mg.

(thiopropazate dihydrochloride )

Indications: Peptic ulcer, spastic constipation,
nonspecific gastritis, functional gastrointesti-
nal disorders, pylorospasm, hyperhidrosis,
irritable bowel syndrome, mucous or ulcerative
colitis, functional diarrhea.

Contraindications: Glaucoma, severe cardiac
disease.

Warnings: Pro-Banthine with Dartal should
not be administered to patients who are under
the influence of barbiturates, alcohol or nar-
cotics. The drug should be administered
cautiously to epileptic patients or those in
depressed states, patients with liver disease
and to pregnant women. Hypersensitivity to
Dartal may occur rarely in patients with
known sensitivity to similar drugs.

Side Effects: Dryness of the mouth, mydria-
sis, hesitancy of urination; less commonly
extrapyramidal (restlessness, dystonia and
signs of pseudoparkinsonism su,:h as muscular
rigidity, fixed facies, tremor, ataxia, festinant
gait and drooling), parasympatholytic
(blurred vision, xerostomia, hypotension, na-
sal congestion and constipation) and curare-
like (loss of control of voluntary muscles,
particula.iy the muscles of respiration) reac-
tions. Rarely, leukopenia or allergic purpura.
A generalized erythematous skin reaction may
occur. Side effects characteristic of pheno-
thiazines such as grand mal convulsions, altered
cerebrospinal proteins, cerebral edema, poten-
tiation of the effects of atropine, heat or phos-
phorus insecticides, autonomic reactions,
endocrine disturbances, reversed epinephrine
effect, hyperpyrexia or pigmentary retinopa-
thy may theoretically occur but have not been
reported with Dartal. Severe hypotension fol-
lowing recommended doses occurs more
commonly in patients who are also afflicted
by other medical disorders such as mitral
insufficiency or pheochromocytoma, and par-
ticular attention should be paid to such a
possibility although this has not been observed
with Dartal.

Adult Dosage: One tablet three times a day.

Pro-Banthine® 15 mg.

(propantheline bromide)
with

Phenobarbital 15 mg.

Warning: May be habit-forming.

For Indications, Contraindications, Precau-
tions, Side Effects and Dosage see Pro-Ban-
thine. In addition, phenobarbital should be
administered with caution to patients with
liver disease, mental disturbances or a signifi-
cant degree of hypoxia.

Pro-Banthine P. A.®

prolonged acting brand of propantheline bromide
For Indications, Contraindications, Precau-
tions and Side Effects see Pro-Banthine.
Dosage Form: Capsule-shaped, compression-
coated, peach tablets of 30 mg. for oral use.
Dosage: The recommended initial dosage is
one tablet in the morning and one at night.

084

Research in theservice of medicine.
G. D. Searle &Co., Chicago, III. 60680

SEARLE

Newborn Hematology / Pullen and Smith

platelet counts during the first weeks of life.3* 8
This was noted particularly in some very im-
mature newborns (less than 1,700 grams birth
weight). If petechiae or other bleeding is present
in a newborn in the presence of thrombocyto-
penia, the thrombocytopenia should not be con-
sidered physiologic.

Petechiae and thrombocytopenia in the new-
born period should always arouse the suspicion of
infection. Almost all severe bacterial infections,
particularly gram negative sepsis, can cause
platelet destruction as well as hemolysis. Throm-
bocytopenia, in the presence of hepatosplenomeg-
aly, suggests cytomegalic inclusion disease, toxo-
plasmosis or lues, and may be seen in the rubella
syndrome.

Many drugs may cause thrombocytopenia in a
hypersensitive recipient. In particular, sulfona-
mides, quinine and quinidine may cause throm-
bocytopenia in an occasional mother and in
her baby if the drug is administered to the
mother near term.

THIAZIDE DERIVATIVES

Chlorothiazide diuretics do not cause mater-
nal thrombocytopenia; however, maternal thiazide
administration during pregnancy occasionally re-
sults in thrombocytopenia in the newborn baby.8
This effect is apparently through suppression of
platelet production by the fetal bone marrow.
This thrombocytopenia may be fairly severe, and
may persist for as long as three months. In view
of the large number of women taking thiazide
derivatives during pregnancy, it is apparent that

TABLE 5

VITAMIN K CONTENT OF CERTAIN MILKS AND
MILK SUBSTITUTES IN MICROGRAMS/LITER
OF STANDARD DILUTION

Cow's milk 60

Skimmed cow’s milk 35

Human milk 15

Sobee 80

Mull-soy 7 1

Enfamil 40

Similac 35

Nutramigen (casein hydrolysate) 18

Gerber’s meat base 16

Gerber's lambase 7

Isomil 17-36*

* Recently changed to 150 mg. /1. 18
From Williams et al, Ped. 44:745, 1969.

neonatal thrombocytopenia only rarely results
from this drug.

The term immune thrombocytopenia is used to
designate thrombocytopenia in which antiplate-
let antibodies cause platelet destruction. Unfor-
tunately, platelet antigens and antibodies are dif-
ficult to identify with most currently employed
serological methods, so that only a few centers
attempt to demonstrate antiplatelet antibodies.
Therefore, the diagnosis of immune thrombo-
cytopenia must often be one of exclusion or of
high suspicion. Platelet antibodies in baby’s se-
rum are transplacentally acquired maternal anti-
bodies, and may be acquired by the baby in
either an active or a passive fashion.

PLATELET INCOMPATIBILITY

Actively acquired, isoimmune, thrombocyto-
penia occasionally occurs when incompatibility
exists between the platelet antigens of the fetus
and those of the mother. (This usually involves
the platelet PlA1 antigen, which only 2 per cent
of people lack, but which causes over half of ma-
ternal platelet isoimmunization.)9 This disorder
due to fetal-maternal platelet incompatibility is
analogous to neonatal hemolytic disease due to
fetal-maternal red cell incompatibility.10 In ac-
tively acquired neonatal thrombocytopenia, the
maternal platelet count is normal while the ba-
by’s platelet count is low.

Maternal sensitization to baby’s platelets is as
likely to occur with the first, as with subsequent
pregnancies. Most infants with isoimmune throm-
bocytopenia have only generalized petechiae,
which are usually present at delivery, or within
a few hours thereafter. However, more severe
bleeding may occur. There is about a 12 per
cent mortality in babies with actively acquired
thrombocytopenia, death usually resulting from
intracranial hemorrhage. Most babies with this
type of thrombocytopenia have a gradual return
of the platelet count to normal, the count usual-
ly being greater than 60,000/MM3 by two to
three weeks of age.10

ANTIPLATELET ANTIBODIES

In passively acquired neonatal thrombocyto-
penia, maternal isoimmunization to fetal plate-
lets does not occur. Rather, the mother, usually
prior to pregnancy, has developed autoimmune
antibodies against her own platelets. During
pregnancy, these antibodies may traverse the
placenta and cause thrombocytopenia in the ba-
by. In this case, both the maternal and neonatal
platelet counts are low. Mothers with lupus or
other collagen diseases or with chronic idiopathic
thrombocytopenia purpura are particularly prone
to pass antiplatelet antibodies on to their in-
fants.

550

JOURNAL MSMA

TABLE 6

NEWBORN HEMOSTATIC DEFECTS*

Most babies with passively acquired immune
thrombocytopenia are only mildly affected,
with only a few showing significant bleeding.2
Duration of the thrombocytopenia varies greatly
(from one week to four months), but the risk
of active bleeding seems to be greatly decreased
after the first few days of life.

Other causes of neonatal thrombocytopenia
are outlined in Table 4, which sketches one differ-
ential diagnostic approach to thrombocytopenia
in the newborn.

HEMOPHILIA

Though hemophilia (inherited deficiency of
plasmatic coagulation factor VIII or IX) is an
uncommon cause of hemorrhage in the newborn,
it should always be ruled out in the bleeding
male infant.11 Family history is often sugges-
tive. Since maternal factor VIII and factor IX
do not cross the placenta, the hemophiliac baby
is born with an already low level of the hemo-
philiac factor. Therefore, it is surprising and un-
explained that hemophiliac babies almost never
develop bleeding from birth trauma. Usually, the
hemophilia is not suspected in the nursery unless
the child is circumcised or requires other minor
surgical procedures. After circumcision, the hemo-
philiac baby often has oozing from the circum-
cision site for several days.

An occasional hemophiliac baby will develop
a cephalohematoma, bleeding from the umbilical

cord or extensive bruising. Once the diagnosis of
hemophilia is affirmed, it is most important to
document the type of hemophilia, since specific
concentrates of either factor VIII or factor IX are
now available for therapy. If a hemophiliac baby
does have bleeding in the newborn nursery, treat-
ment should be with transfusion of fresh whole
blood, fresh plasma or fresh-frozen plasma or
with specific concentrates.

Whereas the hemophiliac is deficient in only
one coagulation factor, multiple factor deficien-
cies occur in some of the mom common syn-
dromes of abnormal hemostasis in the newborn.

LIVER IMMATURITY

Many of the plasmatic coagulation factors,
namely factors V, VII, IX, X, XI, prothrombin
and fibrinogen are synthesized by the liver. In
all newborn infants, some degree of liver im-
maturity exists. In the term infant and in the pre-
mature of high birth weight, liver immaturity is
seldom of sufficient degree to cause significantly
deficient synthesis of coagulation factors. How-
ever, in the low birth weight premature, extreme
liver immaturity may result in significantly low
levels of the liver-synthesized coagulation factors,
and bleeding may result. This type of bleeding
has been called “secondary” hemorrhagic dis-
ease of the newborn.12 It does not respond well
to vitamin K, and must be treated by infusion of
fresh blood or plasma to supply the deficient fac-
tors.

OCTOBER 1970

55 1

Newborn Hematology / Pullen and Smith

In the synthesis of certain of the coagulation
factors (factors VII, IX, X and prothrombin),
the liver must utilize vitamin K. Normal new-
borns are in a somewhat precarious state as to
vitamin K availability. The bacterial intestinal
flora, an important source of vitamin K in the
older child and adult, is not established in the
newborn until several days after birth. Dietary
intake of vitamin K is low during the first days of
life. Because of the deficient supply of vitamin
K, newborns “normally” demonstrate mild de-
ficiencies of the K dependent clotting factors in
the first two to five days of life.12 In a few infants,
these factor deficiencies are exaggerated enough
to cause clinical bleeding, the so-called “classi-
cal” hemorrhagic disease of the newborn.

When hemorrhagic disease secondary to vita-
min K deficiency occurs, the neonate may bleed
profusely from capillary and veni-puncture sites
and occasionally from the umbilical cord. The
infant may demonstrate hematomas in skin or
muscle, gastrointestinal bleeding, hematuria and
rarely hemorrhage into internal viscera or the
central nervous system.

VITAMIN K PROPHYLAXIS

Prophylactic administration of vitamin K to the
newborn prevents hemorrhagic disease due to
vitamin K deficiency. It has been shown that
high doses (greater than 10 mg.) of the syn-
thetic, water-soluble vitamin K analogues (Men-
adione, Synkavite, Hykinone) may result in hy-
perbilirubinemia and kernicterus. The current
recommendation for vitamin K prophylaxis in the
newborn, for both term and premature infants, is
1 mg. of naturally-occurring vitamin Kj (Aqua-
mephyton, Konakion) or 1 mg. of synthetic wa-
ter-soluble vitamin K (Hykinone) administered
intramuscularly to the newborn at birth. Death
and morbidity from vitamin K deficient hemor-
rhagic disease of the newborn can be safely pre-
vented by this simple prophylactic procedure.12- 13

When hemorrhagic disease occurs in an
infant who has not received vitamin K prophy-
laxis, treatment consists of the intravenous or
intramuscular administration of 1 to 2 mg. of
vitamin FL ( Aquamephyton, Konakion). The
intravenous route is preferred if a superficial vein
is available, since intramuscular injections may
cause hematomas. For intravenous administra-
tion, vitamin K should be diluted with a small
amount of saline and injected slowly.

If vitamin K deficiency is the cause of the
bleeding, response to therapy is striking. Hemor-

rhage slows within two hours and an improve-
ment in the coagulation studies can be demon- 1
strated within four hours, with complete correc-
tion within 12 to 24 hours. If hemorrhage is life-
threatening or extensive, initial transfusion with
fresh whole blood is indicated, while waiting for
vitamin K effect.

With widespread adoption of routine vitamin
K prophylaxis in the newborn nursery, hemor-
rhagic disease due to vitamin K deficiency has
become increasingly rare during the first week of
life. However, physicians are less alert to the
possibility of vitamin K deficient hemorrhagic
disease occurring after the first week of life, usu-
ally in premature infants up to about four months
of age.14 When this happens, certain predispos-
ing factors are usually present. Chronic diarrhea
and/or long-term broad spectrum antibiotic ther-
apy may deplete the gut flora.

INADEQUATE INTAKE

Vitamin K intake is inadequate if the infant is
receiving only intravenous feedings. It may also
be inadequate if the infant is on a formula with a
vitamin K content less than that of cow’s milk. In
particular, some milk substitute formulas best
tolerated by infants with chronic diarrhea have a
relatively low vitamin K content. The vitamin K
content in these formulas is sufficient in a healthy
baby, but may not be adequate in the face of an
inadequate bacterial gut flora. Breast milk is also
low in vitamin K. Table 5 lists the vitamin K con-
tent of some commonly employed formulas. Ap-
parently, vitamin K deficiency beyond the first
week of life develops only when low intake and
low intestinal supply co-exist. Supplemental vita-
min K should be administered to infants who
have diarrhea and/or are receiving antimicrobials
if the dietary intake of vitamin K is low. This
prophylactic vitamin K may be administered oral-
ly or intramuscularly. A dosage of 0.1 mg. per
day is probably more than adequate.

DRUG INTERFERENCE

Note should be taken also of the fact that in
mothers taking Dicumarol, the anticoagulant
crosses the placenta and may cause hemorrhage
in the newborn and possibly in utero. Dicumarol’s
anticoagulant effect is exerted through interfering
with vitamin K utilization. Maternal heparin does
not cross the placenta. Hemorrhage occurs in
some infants born to mothers on anticonvulsant
drugs.15 This is apparently due to drug inter-
ference with vitamin K synthesis.

Recent reports suggest that intravascular coag-
ulation (I.V.C.) may be triggered in the new-

552

JOURNAL MSM A

born by some of the same stimuli (i.e. sepsis,
shock) which can cause I.V.C. in the older
child.17 There have been occasional reports of
an infant with coagulation defects born to a
mother with “acute defibrination” syndrome.

In I.V.C., multiple coagulation deficiencies
(platelets, prothrombin, V, VIII and fibrinogen)
develop, due to the fact that these coagulation
factors are consumed in clotting. Undoubtedly
I.V.C. can occur in the newborn period and, if
recognized, might be successfully treated with
heparin. However, in view of the “normally” pre-
carious coagulation mechanism in the immature
infant, predisposing to multiple coagulation fac-
tor deficiencies, the difficulty in rapid, accurate
diagnosis of I.V.C. in these infants can be readily
appreciated. Heparinization would perpetuate
bleeding in the hemorrhagic syndromes other
than I.V.C. Few studies have been done to in-
vestigate I.V.C. in the newborn period. It is ap-
parent that more work needs to be done in this
field before definitive suggestions can be made.

Table 6 presents a laboratory screening ap-
proach to the differential diagnosis of hemostatic
defects in the newborn. When a blood sample is
drawn for coagulation studies from a newborn
suspected of having a hemostatic defect, the
blood should not be obtained from a femoral
or a neck vein, since prolonged oozing from these
areas may be hazardous. A small sample can
usually be obtained from an antecubital or scalp
vein by using a “Butterfly” infusion set and
syringe for blood withdrawal.

TRANSFUSION AXIOMS

When transfusion is required during the new-
born period, the following points should be kept
in mind:

Acute blood loss is best replaced with whole
blood, dosage not to exceed 20 ml. /kg. in one
transfusion. Chronic blood loss is best replaced
with packed cells, dosage not to exceed 10 ml./
kg. in one transfusion. Anemia from hemolysis is
best corrected with packed cells. If the hemolysis
has resulted in significant hyperbilirubinemia, ex-
change transfusion with fresh whole blood may
be required (to be discussed in a subsequent
article in this series). If transfusion is required
for bleeding secondary to a plasmatic coagula-
tion defect, fresh (less than three hours old)
blood or plasma should be used. If one uses

fresh blood to transfuse a patient with a coagula-
tion defect, that blood should not be collected in
heparin.

Blood given to a neonate should be cross-
matched against both maternal serum and the
baby’s red cells and serum. If, in a true life-
threatening emergency, this crossmatching is im-
possible, blood from the mother may be given
to the baby or blood from an O negative donor
may be administered. ***

2500 N. State Street (39216)

REFERENCES

1. Oettinger, L. and Mills, W. B.: Simultaneous capil-
lary and venous hemoglobin determinations in the
newborn infant. J. Pediat. 35:362, 1949.

2. Smith, C. A.: The Physiology of the Newborn In-
fant. Charles C Thomas, Springfield, 1959.

3. Oski, F. A. and Naiman, J. L.: Hematologic Prob-
lems in the Newborn. W. B. Saunders, Philadelphia,
1966.

4. Usher. R., Shepard, M. and Lind, J.: The blood
volume of the newborn infant and placental trans-
fusion. Acta Paediat. 52:497, 1963.

5. Erlandson, M. E. and Hilgartner, M.: Hemolytic
disease in the neonatal period and early infancy.
J. Pediat. 54:566, 1959.

6. Pochedly, C. and Ente, G.: Fetal bleeding, a dual
menace. Postgrad. Med. 45:159, 1969.

7. Erlandson, M. E.: The acute anemias of the perinatal
period, in Resuscitation of the Newborn Infant by
Abramson, H., Editor. C. V. Mosby, St. Louis, 1966.

8. Medoff, H. S.: Platelet counts in premature infants.
J. Pediat. 64:287, 1964.

9. Adner, M. M., Fisch, G. R., Starobin, S. G. and
Aster, R. H.: Use of “compatible” platelet transfu-
sions in the treatment of congenital isoimmune
thrombocytopenic purpura. N.E.J.M. 280:244, 1969.

10. Pearson, H. A., Shulman, N. R., Marder, V. J. and
Cone, T. E., Jr.: Isoimmune neonatal thrombocy-
topenic purpura: clinical and therapeutic considera-
tions. Blood 23:154, 1964.

11. Baehner, R. L. and Strauss, H. S.: Hemophilia in
the first year of life. N.E.J.M. 275:524, 1966.

12. Aballi, A. J. and deLamerens, S.: Coagulation
changes in the neonatal period and earlv infancy.
Pediat. Clin. 9:785, 1962.

13. Vietti, T. J., Stephens, J. C. and Bennett, K. R.:
Vitamin Ki prophylaxis in the newborn. J.A.M.A.
176:791, 1966.

14. Goldman, H. I. and Amadio, P.: Vitamin K de-
ficiency after the newborn period. Pediat. 44:745,

1969.

15. Evans, A. R., Forrester, R. M. and Discombe, C.:
Neonatal hemorrhage following anticonvulsant ther-
apy. Lancet 1:517, 1970.

16. Williams, T. E., Arango, L., Donaldson, M. H. and
Shepard, F. M.: Vitamin K requirement of normal
infants on soy protein formula. Clin. Pediat. 9:79,

1970.

17. Hathaway, W. E., Mull, M. M. and Pechet, G. S.:
Disseminated intravascular coagulation in the new-
born. Pediat. 43:233, 1969.

OCTOBER 1970

553

Radiologic Seminar C
Roentgen Diagnosis
of Anencephaly in Utero

SAM LEVI, M.D.
Ocean Springs, Mississippi

When presented with a patient who has en-
larged out of proportion to the duration of preg-
nancy, the physician frequently orders an x-ray
study, to differentiate between twins and hydram-
nios. Since hydramnios is frequently associated
with fetal abnormality, it is important to care-
fully study the fetal skeleton. One of the most
common monstrosities is anencephaly, fortu-
nately, the diagnosis is usually simple, namely an
absence of the vault of the skull, but presence of
facial bones and an unusual cluster of small dense
masses in the region of the base, as well as an
apparently short neck.

An error in diagnosis can occur when the film
is exposed during fetal movement and the entire
skeleton is essentially blotted out. Abnormally
active, and when manually palpated, convulsive
fetal movements have been described as impor-
tant presumptive signs of anencephaly.

The patient, age 23, gravid 4, para 3, was re-
ferred by Dr. E. M. Baumhauer for roentgen
studies because of suspected hydramnios. The
technician made anteroposterior and lateral stud-
ies and called the films to my attention because
no fetal skeleton was apparent. Recalling another

Sponsored by the Mississippi Radiological Society.

case when no fetal skeleton was evident on the
initial study, but present on repeat films, I ques-
tioned the patient as to whether the baby moved
during x-ray exposure. She replied “Yes, it was
turning summersaults,” and added that this was
the most active of her babies.

The patient was then informed that fetal move-
ment blurred the picture and was instructed to
state when the baby was quiet for a repeat study.
Additional films showed typical anencephalic
deformity. A live 3 pound, 3 ounce female fetus
was delivered one week later after elective in-
duction.

SUMMARY

1. Anencephaly is frequently associated with
hydramnios.

2. Unusually active fetal movements should
arouse clinical suspicion of anencephaly, particu-
larly if the patient has had a previous monster.

3. Absence of cranial vault, a cluster of small
dense masses with facial bones and apparently
short neck is characteristic.

4. A rare source of error can be avoided by
instructing the patient to inform the technician if
fetal movement is present during x-ray exposure.

554

JOURNAL MSM A

Figure 1. AP abdomen reveals faint smudge in
maternal pelvis which should arouse one’s suspicion.

Figure 2. Typical appearance of anencephaly. Note
closed arrow pointing to well-developed femur and
lower open arrow pointing to deformed skull.

REFERENCES

1. Snow, W. and Nadel, N.: Roentgen Study of the
Fetus in Utero, Some Practical Considerations. Radi-
ology 42:136-142, February 1944.

2. Baman, R.: Obstetrics and Gynecology. 183-385,
Philadelphia. Penn., F. A. Davis Co. 1955.

3. Maloy, H. C. and Swenson, Paul: The Use of Roent-

gen Ray in Obstetrics. 10.8, Baltimore, Md., Williams
and Wilkins Co. 1969.

4. Hirst, J. C.: Monsters; Cylopedia of Medicine and
Surgery. 9:245-246, Philadelphia. Penn., F. A. Davis
Co. 1954.

5. Bishop, P. H.: Radiological Studies of the Gravid
Uterus. 166-167, New York, N.Y., Hoeber Medical
Division. Harper and Row, Publishers. 1965.

ACADEMIC DISADVANTAGED

A bearded, sweat shirt-clad hippy type pushed his loaded
shopping cart into the express check lane where the sign offered
service for “six or fewer packages.”

The supermarket checker looked at the full cart and asked:

“Are you one of those MIT students who can’t read or just a
Harvard student who can’t count?”

OCTOBER 1970

555

The President Speaking

‘Growing Pains’

PAUL B. BRUMBY, M.D.
Lexington, Mississippi

The MSMA was asked to appear before the legislative investi-
gating committee to explain why in our opinion only $7.8 million
of the $17 million appropriation to Medicaid for its first six
months of operation was not spent. The return of this money,
83 per cent of which was from federal sources, has caused much
publicity.

The Medicaid operation is extremely complex, interrelating
with the Welfare Department which must certify eligibility, the
Medicare program, a federal operation which through Travelers
pays the provider of services for those on Old Age Assistance
except the deductibles which are paid through Medicaid. Medicaid
had less than three months to implement the whole Medicaid pro-
gram, although a fiscal agent had neither a staff nor hardware to
effectively support this program.

The Medicaid commission consisting of four members of the
legislature and three outstanding citizens with the staff headed by
an outstanding medical association member had to start from
scratch, but to show its growth the fiscal agent received 5,000
claims in is first month of operation. In July they received 37,000
claims and claims from over 68 per cent of the Mississippi phy-
sicians who are in private practice. It was only in February that
the 86,000 dependent children could be added to its roll, and it was
only in July that the tremendously expensive drug program could
be implemented. They received over 100,000 prescriptions during
July. The nursing home program, usually accounting for 43 per
cent of expended funds is still not off the ground. The $250.00 a
month limitation on payments will not buy nursing home care.
The reports show the physician to have received 39 per cent of the
total payout, with little explanation of the cause of this. The first
program implemented was for direct medical care and provider
services were paid, but of the $3,242,000.00 supposed to have
gone for physicians services, $1,611,000.00 was paid as a buy-in
to Part B of Medicare with all of its various programs. How
much of this was paid to providers of medical care we do not
know.

Medicaid is improving and we hope it will continue to improve.
This is a state program we can talk to, we can suggest, we can
criticize, but remember Medicare only tells us. Medicaid is having
growing pains but it is maturing.

556

JOURNAL MSMA

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 10
OCTOBER 1970

Medical Care Foundations:
Private Delivery That Works

I

Health care delivery has become as much of
an American household word as Spiro Agnew,
environment, and ecology. The President of the
United States has characterized the delivery sys-
tem as being in a state of crisis. Most of its critics
— and they abound aplenty throughout the land
— say that it is no system at all but rather a cot-
tage industry. Still other voices charge that the
delivery system is unorganized, a maze of inde-
pendent, yet somehow related, fragments.

None of this is all true, but American medical
leadership readily concedes that the system faces
severe challenges. Perhaps Dr. James L. Royals
of Jackson, the association’s 1969-70 president,
summed it up with greater candor and concise-
ness than others when he said that the system
“is on trial.”

“I do not claim perfection for our care de-
livery system,” Dr. Royals said in his presidential
address to the 102nd Annual Session. Confess-
ing discomfort with change, he pointed out with
frankness that “we must recognize that we are
living in a dynamic time, a time of rapid and dra-
matic change, of new and varied social forces, of
miraculous technology, and of troubled political
balance in a volatile world.”

But the change of which medicine’s leaders
as well as its critics speak may not be so drastic
after all. In fact, say many who are awakening
to something which we have largely ignored, the
change is of medicine’s making, and it is already
here.

The name of the change is the medical care
foundation which happens to be alive and well
and delivering medical care in half a dozen states
to nearly 2 million Americans.

II

Born in California, the birthplace of so many
innovations in care financing and delivery, the
medical care foundation is a creature of medi-
cal organization and private practice. As such,
one could think it suspect as being just another
production model of the system’s guild for per-
petuation of the cottage industry.

Not so, say a million Californians who are
free to choose their physician and receive the
care which his professional judgment dictates.

Not so, say private and insurance companies
and voluntary prepayment plans which are pick-
ing up the tab with a great deal more enthusiasm
than in before-foundation times.

Not so, say consumer and employee representa-

OCTOBER 1970

557

EDITORIALS / Continued

tives groups, unions to most of us, who find that
the guarantee of care delivery is being honored.

Not so, say governmental agencies charged
with administration of tax-supported medical care
programs who find their costs predictable and
their actuarial planning sound.

The medical care foundation is a voluntary,
nonprofit membership organization incorporated
under the sponsorship of a medical association.
Its owners are physicians; its members are phy-
sicians; and its bosses are physicians elected to
office by physician-members.

The MCF has four simple functions which are
crucially important in all the sound and fury
about medical care in America today:

— It provides the means for the medical pro-
fession to assume direct responsibility for and
leadership in the delivery of medical care. How?
By overseeing services provided by its own.

— The MCF receives and processes claims for
professional services, and in most cases, makes
payment within a preagreed frame of just and
equitable fee ranges.

— It conducts peer review which is to say that
physicians oversee their own houses.

— And it sponsors utilization review, making
certain that expensive and sometimes scarce fa-
cilities are optimally employed at maximum
possible efficiency.

A medical care foundation is served by a
skilled staff under the supervision of its physician-
members, mostly within the structure of the spon-
soring medical association. These workers gen-
erally include medical executives experienced in
care plan administration, claims adjudicators
and processors, data processing personnel, and
those skilled in accounting and statistical services.

Ill

What a medical care foundation is and is not
counts for everything in understanding the nature
of the critter. Every MCF organized to date has
as its purposes at least these five salient goals:

— To promote, develop, and encourage the
distribution of medical services to the area it
serves at a cost which is just and equitable to
patient and physician.

— To preserve freedom of choice both to pa-
tient and physician.

— To guard, preserve, and foster the physician-
patient relationship in the traditional, time-hon-
ored sense.

— To protect the public health.

— And to work cooperatively with private in-

surance, voluntary prepayment, and tax-support-
ed medical care plans to provide for periodic and
realistic budgeting of just and proper costs.

A medical care foundation is not a union. It
doesn’t bargain professional fees nor is it a closed
shop where nonmenber physicians are out in the
cold world of lay-sponsored care programs left
to shift for themselves. The MCF does not and
cannot affect the membership status of any phy-
sician, a feature implicit in the Mississippi State
Medical Association’s peer review policies adopt-
ed by the House of Delegates this year. It does
not and cannot affect the right of any physician
to practice medicine.

A medical care foundation is not an insurance,
prepayment, or government medical care pro-
gram. As such, it doesn’t have a dime of its own,
except for at-cost charges made for its services
and possibly some nominal dues barely sufficient
to sustain the skeleton administrative functions of
minutes-keeping and the like. The MCF draft
authority for paying out professional fees under
peer and utilization review by physicians is a re-
sponsibility it is willing to assume. And it makes
a stern stewardship accounting for this function,
as it does for all its activities.

A medical care foundation is not the answer
to every problem facing the health care delivery
system today, but it is a system and one that
works quite well in the hands of serious, honor-
able members of the medical profession.

Membership in the MCF by physicians is volun-
tary, and all foundations require annual renewal
by application. The organization is governed by
a Board of Trustees elected by the voluntary
membership, and there are committees for peer

558

JOURNAL MSMA

review, utilization review, membership, and other
purposes as needs require.

The MCF is therefore an extension of the
sponsoring medical association consisting of those
members who desire to avail themselves of its
services, joining in preserving private practice tra-
ditions while meeting the serious challenges to the
care delivery system. A logical question for the
uninitiated, then, is why have a foundation at all,
if my medical association already administers a
medical care plan and possesses the skill, ex-
pertise, trained staff, and hardware to process
claims for professional services?

Why a MCF if our association has made a
major commitment to peer review at state and
component society levels? Why a foundation
when our association-administered medical care
plan has usual and customary fees, area and not
individual fee profiles, and does all these things
without another organization to join?

The answer is just as logical: The medical care
foundation can do things a medical association
does not ordinarily undertake and in some cases,
may not. The MCF can enter into agreements
with corporations, employee groups, insurance
companies, care plans of every sort, and others to
deliver care within a framework which is mutual-
ly acceptable. But even more than this, it stands
between the provider and the third party as advo-
cate of patient and physician.

The MCF has no fish to fry politically nor is it
crusading for or against a pending proposal. The
foundation takes the situation as it is and makes
it work for private care delivery under physician-
sponsorship and terms acceptable to all parties
concerned. It does not retail medical care but in
stock exchange language, it assures an orderly
market for fair trading.

It is a health care delivery system with the
best of both worlds: The world of traditional
American private practice and the honored phy-
sician-patient relationship and the new world of
third parties which are here to stay.

IV

Sixteen medical care foundations are going
concerns in California serving nearly 1 million
patients and 6,000 physicians. Statewide founda-
tions, much better suited for less populous areas,
are operational in Colorado and New Mexico. The
latter are operating Medicare and Medicaid.

More statewide MCF’s are on the drawing
boards, late planning stages, or on the threshold
of operation in Arizona, Florida, Georgia, Hawaii,
Iowa, Minnesota, and New York. When the latter
becomes a reality, it will be the U. S. giant, for

the Medical Society of the State of New York,
the nation’s biggest medical association, has long
operated workmen’s compensation, CHAMPUS,
and a number of other medical care plans.

Once established, this array of coast-to-coast
MCF’s will potentially represent 50,000 practic-
ing physicians and as many as 40 million pa-
tients. This is a substantial quantity in anybody’s
measure and a health care delivery system which
simply cannot and will not be ignored. Its back-
bone is medical organization without which no
foundation could be brought into being.

This success story should not be interpreted
as advocacy for Mississippi, because the state
medical association has not spoken officially on
the medical care foundation. But it is an issue far
too important to private practice for the associa-
tion to ignore. Dr. Royals exhorted Mississippi
medicine to be “master of its own house,’’ calling
for a serious, working peer review system. The as-
sociation already possess the personnel and tools
and know-how to conduct the staff work for the
foundation. A commitment has existed for dec-
ades to deliver the best possible medical care to
all Mississippians within the traditional frame of
the honored physician-patient relationship.

It is just common sense for every physician in
the state to inform himself on medical care foun-
dations, to discuss this issue with his colleagues, to
make his wishes known, and to cause his as-
sociation to debate the matter. — R.B.K.

An Economic Asset
of MSMA Membership

A vast majority of American physicians would
just as soon meet a hungry tiger and take him on
with a curette as grapple with the knotty prob-
lem of professional liability insurance. Mississippi
physicians, however, have been extremely for-
tunate in this respect, and it is not altogether by
accident, either.

In 1961, the state medical association’s Board
of Trustees had the foresight to recognize an in-
cipient crisis somewhere down the line in this
vital coverage. There was, almost a decade ago,
a pronounced trend upward in premium costs,
and the big jury awards in malpractice suits were
beginning to make the news.

Regrettably, many state medical associations
either failed to grasp the implication of the trend
or else chose to do nothing, hoping that it, like
yellow fever and pellagra, would yield to a po-
tent economic antibiotic or vitamin and just go
away.

OCTOBER 1970

5 59

EDITORIALS / Continued

The Mississippi association conferred with in-
surance carriers, their trade association then
known as the National Bureau of Casualty Under-
writers, and representatives of the State Insur-
ance Commission. We found only casual interest,
some indifference, and much resignation to in-
evitably higher premiums. This made the Board
and its then-chairman, Dr. H. H. McClanahan,
Jr., of Columbus, even more determined to do
something, and do this they did.

An agreement was entered into with the St.
Paul Companies of Minneapolis-St. Paul, a re-
spected old line group represented by knowledge-
able, aggressive agents who agreed that there
was a job to do. A state medical association pro-
fessional liability insurance “group” was orga-
nized in the summer of 1961.

It wasn’t really a group in the classic insurance
sense, because there was not then nor has there
ever been any mass enrollment. Each applicant
physician is written on the basis of his own merit,
type of practice, and membership in his local
society, Mississippi State Medical Association,
and AM A. He need not be a fellow of any
American college of this-or-that, nor does he
need to be a diplomate of any board.

He purchases his coverage through a local in-
dependent insurance agent, lately of “Big I”
identification, because the association has always
advised physicians to buy insurance coverage lo-
cally where an established agent resides and does
business. And we have said that he should buy
enough insurance, because when more is needed,
it usually isn’t for sale!

The St. Paul professional liability program grew
slowly, and at times, it appeared to be of no
particular significance in terms of mass purchas-
ing power, the reason most often advanced for
having insurance groups.

But the program paid off within six months of
its inception: The NBCU companies (St. Paul,
although strong and reputable, has never been a
Bureau company ) announced a lowering of pre-
mium rates. That was just after St. Paul an-
nounced a price cut. Clearly, the trend in Missis-
sippi was reversed.

Within two years, more than half of the states
had experienced increases in professional liability
insurance premiums, while, of all things to hap-
pen, the rate went down again in Mississippi. And
participation in the program was growing.

The agreement has always been a two-way
street: St. Paul makes a full stewardship ac-
counting of the program to the association’s

Board of Trustees, and the Board has willingly
and generously given its time and know-how in
advising on threatened or instituted malpractice
litigation. This, of course, is the secret of the pro-
gram which is no secret at all.

Developments since 1968 are part of Ameri-
can medicine’s economic headlines. The cost of
professional liability insurance has become a
nightmare for nearly half of all American practi-
tioners. A California surgeon must pay an abso-
lute minimum of about $4,100 for 100/300 cov-
erage, and few are able to purchase it for that
price. His Mississippi counterpart pays roughly
$600 for the same coverage.

In neighboring Alabama, new rates just an-
nounced price the surgeon’s 100/300 coverage at
$1,400, and the story is about the same in most
other states.

Dr. McClanahan, really the father of the pres-
ent program, once said that “if the Mississippi
State Medical Association had never done an-
other thing for its members, the professional lia-
bility insurance program has been enough in
dollar savings to pay all local, state, and AMA
dues from here on in with profit to spare.”

If this were true when Dr. McClanahan said
it, how much truer it is today, because Mississippi
has the fourth lowest state professional liability
insurance premium rate in the United States by
the standard insurance manual, and the St. Paul
program is 10 to as much as 20 per cent below
the book!

5 60

JOURNAL MSM A

This is a program to be prized by the member-
ship, and there are now 650 participants. Of
course, there are other good and reputable in-
surance carriers besides St. Paul, and the associa-
tion fully respects and supports them, too. We do
say that the St. Paul pioneering concept and the
association’s far-looking action through the Board
of Trustees has helped everybody.

If, as Dr. McClanahan said, for no other rea-
son, medical association membership in Missis-
sippi is a pretty valuable economic as well as
professional asset. — R.B.K.

Like, Man, This
Splits From Webster

Anybody who enjoys a wide range of contact
with children, especially the marvelous teenagers
of today, knows that they have an “in'’ language.
And, man, this lingo is like so far out that one
comes to be convinced that there is really no
generation gap at all — just a language barrier.

A Memphis child psychiatrist, Dr. Morris D.
Cohen, may just have cracked the barrier, be-
cause he has compiled a new reference source,
The Now 70’s Language Dictionary.

Nor is this a paperback for an evening’s enter-
tainment of wonder about “black widow” for
methamphetamine or “speed” for methadone.
The book isn’t groovy for the sake of finding out
what “third world” people think and do. It is an
honest-to-goodness scholarly work about how this
sometimes unbelievable generation communicates.

No less distinguished body than the Council
on Child Health of the American Academy of
Pediatrics considered the book at its summer
meeting in Chicago. Says the AAP Newsletter,
“The publication is being recommended to pedi-
atricians as a valuable information source of cur-
rent teenage terminology and word usage.”

The report continues that “Dr. Cohen has
written his book as an aid to physicians, parents,
and other interested adults who find it essential
to be alerted to specific verbal danger signals
when communicating with teens on their own
level.”

Now, there are some cynics who might take
exception to this purposeful pronouncement, but
the idea is not only intriguing but downright
practical. We congratulate Dr. Cohen for his
obvious resourcefulness, perseverance which
needs no accolade, and willingness to bring an
idea to fruition which might frighten a lesser
person into mild shock.

Like, man, this splits from Webster, so there
is hope that some of us may become bilingual
after all.— R.B.K.

Antisubstitution Kill
Is a Crooked Straw

There is a crooked straw in the wind which has
attracted little attention. But it has the potential
of a log in a hurricane in patient care and the
professional prerogatives of the practicing phy-
sician. At its Washington, D. C., convention, the
American Pharmaceutical Association voted to
seek repeal of state antisubstitution drug laws.

As with the iceberg, only a little of the whole
shows above the surface of the water. The APhA
pronouncement seems mild and simple enough:
“Repeal of antisubstitution laws would not disturb
the existing prescriber-pharmacist relationship or
deprive the prescriber of the right to insist that
a particular drug product be dispensed. . . . Re-
peal would simply act to remove the state as a
decision-maker in the prescribing and dispensing
of medication.”

But that’s just the top of the iceberg. APhA
has long clamored for more professional status for
the pharmacist. He should, they argue, be the
therapeutic member of the health care team. Gen-
erally, these arguments are based on these tenu-
ous premises:

— Pharmacists, not physicians, are the real
drug experts.

— Pharmacists spend more time in pharmacol-
ogy than doctors so they (pharmacists) should
select the drugs for the patient.

— Physicians should only make the diagnosis
and let the pharmacist handle the therapy.

Now, it is difficult to believe that even a sub-
stantial minority of pharmacists really believe this
line of tortured logic. Of course, the profession
of pharmacy has changed over the years, as has
every other health profession. Schools of phar-
macy have six-year curricula, and the training
is solid and substantial.

But pharmacists do not treat patients, nor do
they possess the qualifications to select a thera-
peutic agent on the basis of a diagnosis. It
doesn't take a medical education to understand
this. Antisubstitution laws are on the statute books
for other very good reasons, too, more, in fact,
than the matter of brand name vs. generic
designation or those of mere pricing of the drug
product.

There is the matter of liability, not just for the
pharmacist but also for the physician who is al-

OCTOBER 1970

561

BREAKUP— symbol of the impact of emotional stres
But when the stress exceeds transient rage or
depression — and settles into a chronic mixed anxiety
depression state— combined tranquilizer-
antidepressant therapy could be indicated.

FOR MODERATE TO
SEVERE ANXIETY
WITH COEXISTING
DEPRESSION

TRIAVIL

TRANQUILIZER-

ANTIDEPRESSANT

Containing perphenazine and amitriptyline HCI

For prescribing information, including indica-
tions, contraindications, warnings, precautions,
and side effects, please see following page.

v. ;■

FOR MODERATE TO
SEVERE ANXIETY
WITH COEXISTING
DEPRESSION

TRIAVIL

TRANQUILIZER-

ANTIDEPRESSANT

Containing perphenazine and amitriptyline HCI

TRIAVIL®2-10: Each tablet contains 2 mg. of perphenazine
and 10 mg. of amitriptyline hydrochloride.

TRIAVIL®2-25: Each tablet contains 2 mg. of perphenazine
and 25 mg. of amitriptyline hydrochloride.

TRIAVIL®4-10: Each tablet contains 4 mg. of perphenazine
and 10 mg. of amitriptyline hydrochloride.

TRIAVIL®4-25: Each tablet contains 4 mg. of perphenazine
and 25 mg. of amitriptyline hydrochloride.

INDICATIONS: Patients with moderate to severe anxiety
and/or agitation and depressed mood; patients with de-
pression in whom anxiety and/or agitation are severe;
patients with depression and anxiety in association with
chronic physical disease; schizophrenics with associated
depressive symptoms.

CONTRAINDICATIONS: Central nervous system depression
from drugs (barbiturates, alcohol, narcotics, analgesics,
antihistamines); bone marrow depression; pregnancy; and
in patients with known hypersensitivity to phenothiazines
or amitriptyline. Do not give in combination with MAOI
drugs because of possible potentiation that may even cause
death. Allow at least two weeks between therapies. In such
patients therapy with TRIAVIL should be initiated cau-
tiously, with gradual increase in the dosage required to
obtain a satisfactory response. Do not give concomitantly
with guanethidine or similarly acting compounds since it
may block the antihypertensive effect.

WARNINGS: Patients should be warned against driving a
car or operating machinery or apparatus requiring alert
attention, and that response to alcohol may be increased.
PRECAUTIONS: Suicide is always a possibility in mental
depression and may remain until significant remission oc-
curs. Supervise patients closely in case they may require
hospitalization or concomitant electroshock therapy. Un-
toward reactions have been reported after the combined
use of antidepressant agents having various modes of
activity. Accordingly, consider possibility of potentiation
in combined use of antidepressants. Use with caution in
patients with glaucoma and those with problems of urinary
retention. Perphenazine can lower the convulsive thresh-
old in susceptible individuals. It should be given with cau-
tion to patients with convulsive disorders. Dosage of the
anticonvulsive agent may have to be increased. Not rec-
ommended for use in children. Mania or hypomania may
be precipitated in manic-depressives (perphenazine in
TRIAVIL seems to reduce likelihood of this effect). If hypo-
tension develops, epinephrine should not be employed, as

its action is blocked and partially reversed by perphen1
zine. Caution patients about errors of judgment due
change in mood.

ADVERSE REACTIONS: Similar to those reported wi
either constituent alone.

Perphenazine: Should not be used indiscriminately. U:
caution in patients who have previously exhibited seve
reactions to other phenothiazines. Likelihood of untowa
actions greater with high doses. Closely supervise wi
any dosage. Side effects may be any of those report*
with phenothiazine drugs: extrapyramidal sympton
(opisthotonos, oculogyric crisis, hyperreflexia, dystoni
akathisia, dyskinesia, parkinsonism) usually controlled I
the concomitant use of effective antiparkinsonian druj
and/or by reduction in dosage, but sometimes persi
after discontinuation of the phenothiazine; skin disorde
(photosensitivity, itching, erythema, urticaria, eczema, i
to exfoliative dermatitis); other allergic reactions (asthm
laryngeal edema, angioneurotic edema, anaphylactoid r
actions); peripheral edema; reversed epinephrine effec
hyperglycemia; endocrine disturbances (lactation, gala
torrhea, disturbances of menstrual cycle); altered cer
brospinal fluid proteins; paradoxical excitement; EK
abnormalities (quinidine-like effect); reactivation of ps
chotic processes; catatonic-like states; autonomic rea
tions, such as dryness of the mouth, headache, nause
vomiting, constipation, obstipation, urinary frequenc
blurred vision, nasal congestion, and a change in the pul:
rate; hypnotic effects; pigmentary retinopathy; corne
and lenticular pigmentation; occasional lassitude; muse
weakness; mild insomnia. Other adverse reactions r
ported with various phenothiazine compounds, but n
with perphenazine, include blood dyscrasias (pancyt
penia, thrombocytopenic purpura, leukopenia, agranuloc!
tosis, eosinophilia); liver damage (jaundice, biliary stasis
grand mal convulsions; cerebral edema; polyphagia; ph
tophobia; skin pigmentation; and failure of ejaculatio
Significant unexplained rise in body temperature may su
gest intolerance to perphenazine, in which case disco
tinue. Antiemetic effect may obscure signs of toxicity di
to overdosage of other drugs or make diagnosis of oth
disorders such as brain tumors or intestinal obstructs
difficult. May potentiate the action of central nervoi
system depressants (opiates, analgesics, antihistamine:
barbiturates, alcohol) and atropine. In concurrent the
apy with any of these, TRIAVIL should be given in reduce
dosage. May also potentiate the action of heat and phe
phorous insecticides.

Amitriptyline: Careful observation of all patients recoi
mended. Side effects include drowsiness (may occ
within the first few days of therapy); dizziness; nause1
excitement; hypertension; fainting; fine tremor; jitte
ness; weakness; headache; heartburn; anorexia; i
creased perspiration; incoordination; impotenc
increased appetite and weight gain; allergic-type rea
tions manifested by skin rash, swelling of face and tongp
itching; numbness and tingling of limbs, including p
ripheral neuropathy; activation of latent schizophrer
(however, the perphenazine content may prevent this i
action in some cases); epileptiform seizures; tempore
confusion, disturbed concentration, or transient visi
hallucinations on high doses; evidence of anticholinerf
activity, such as tachycardia, dryness of mouth, stomatit
blurring of vision, reversible dilatation of the urinary tra
urinary retention, constipation, paralytic ileus; agrar
locytosis; jaundice. Elderly patients and adolescents c
often be managed on lower dosage levels.

For more detailed information, consult your MSD Represc
tative or see the package circular. Merck Sharp & Dohn
Division of Merck & Co., Inc., West Point, Pa. 19486.

MSP MERCK SHARP & DOHME

ways finally responsible for his diagnosis and
treatment. There is the matter of implied war-
ranty, of what the drug selected is and is not, and
what side effects the so-called identical agent
might produce.

We respect the profession of pharmacy and
point out that its contributions to health care
have been magnificent. We do not level the
charge of “merchant” instead of professional at
the pharmacist, nor do we degrade his calling
in any sense. But we do say that he fostered and
shaped his profession and that he has no rational
basis for entering a new one now. Unless, of
course, he cares to go on to secure his M.D. when
antisubstitution laws will then make no difference
at all.— R.B.K.

Profile of Our Children,
A Teenage Nation

For the first time in its 70 years of history, the
decennial White House Conference on Children
and Youth will be divided into two sessions. The
first, a Conference on Children, is scheduled
Dec. 13-18. 1970, at Washington, while the sec-
ond stage, the Conference on Youth, will open
in Feb. 1971.

The conclave on children will focus on the age
range of infancy through 13 years, while the
youth segment will relate to ages 14-24. There is
logic in the division, and profile of American
children proves the point.

In this nation of some 205 million, there are
53.3 million children under 14 years of age.
They are, for all intent and purpose, the baby
boom of the post-World War II baby boom. And
this is a growth in this age grouping from 30
million in 1940, almost double.

The demographers tell us that this growth re-
sults from a geometric phenomenon of reproduc-
tion: From 1941 through 1966, the number of
births each year exceeded the number of children
reaching their 14th birthdays.

Just over half of our children are boys, and
their proportion remains static at about 51 per
cent in ages 10 through 13. Racial composition of
our population, however, varies with age, and
the proportion for nonwhites declines from 17.2
per cent of the children under age 5 to 14.4 per
cent at the 10 through 13 bracket.

If only demographically, the division of the
White House Conference makes sense, because
the population segment to be considered is sub-
stantial, significant, and in fact, our next genera-
tion.— R.B.K.

MISSISSIPPI POSTGRADUATE

INSTITUTE IN THE MEDICAL

SCIENCES

Now in its second year, the Mississippi Post-
graduate Institute in the Medical Sciences has
accepted another class of 20 Mississippi phy-
sicians, bringing the total to 40. Last year’s
curriculum of eight one-week refresher courses
has been expanded to 15 to accommodate the
enrollment growth. With the exception of can-
cer chemotherapy, each of the original courses
will be offered twice this year, with registration
again limited to five in each course. Participat-
ing physicians who complete 440 hours in a
four-year program will receive a certificate of
excellence. The Mississippi Regional Medical
Program supports the Mississippi Postgraduate
Institute in the Medical Sciences, which is
sponsored by the University of Mississippi
School of Medicine in cooperation with the
Mississippi State Medical Association. Early
fall courses are:

November 2-6

Electrocardiography Intensive Course
University Medical Center, Jackson
November 2-6, 1970. beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Coordinator:

Thomas M. Blake, M.D., professor of medicine,
The University of Mississippi School of Medi-
cine

Designed for the practitioner who uses elec-
trocardiography in daily rounds but who has
had little formal training in the subject, this
one-week intensive course will utilize dem-
onstrations, lectures, discussions and confer-
ences. Participants will study disorders of car-
diac mechanism, introventricular and atroven-
tricular block, manifestations of coronary ar-
tery disease and ventricular balance.

November 2-6

Radiology Intensive Course

University Medical Center, Jackson
November 2-6. 1970, beginning at 8 a.m.

OCTOBER 1970

565

POSTGRADUATE / Continued

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Coordinator:

Robert D. Sloan, M.D., professor of radiology
and chairman of the department, The Univer-
sity of Mississippi School of Medicine

This one-week intensive course will include
practical observations of radiologic procedures
in the diagnostic, therapeutic and isotope areas,
as well as sessions dealing with equipment,
techniques, artefacts and radiation safety. Di-
agnostic conferences will enable registrants to
understand both the value and limitations of
clinical radiology and the practical points of
radiographic interpretation.

November 9-13

Gastroenterology Intensive Course
University Medical Center, Jackson
November 9-13, 1970 beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Coordinator:

Lidio O. Mora, M.D., associate professor of medi-
cine, The University of Mississippi School of
Medicine, and chief, division of gastroenterol-
ogy, The University of Mississippi Medical
Center and the Jackson Veterans’ Administra-
tion Center

This one-week intensive course, a practical
view of gastroenterology, will cover conditions
most commonly seen in the current office prac-
tice of medicine, with particular emphasis on
endoscopy of all kinds. Registrants will partici-
pate in rounds, lectures and seminars.

November 9-13

Pediatrics Intensive Course
University Medical Center, Jackson
November 9-13, 1970, beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Coordinators:

J. M. Montalvo, M.D., associate professor of
pediatrics, The University of Mississippi School
of Medicine

Nell J. Ryan, M.D., associate professor of pedi-

5 66

atrics, The University of Mississippi School
of Medicine

The lectures in this one-week intensive
course will emphasize fluids, hematology, car-
diology, immunizations, allergies, seizures, pe-
diatric emergencies, pediatric surgery, renal
problems and care of the newborn. Participants
will sharpen their skills in scalp vein tech-
niques, and in the use of the humidifier, res-
pirator, nebulizer and resuscitator.

CIRCUIT COURSES
Northern Circuit

Tupelo — September 22 — Session 1; October
20 — Session 2; November 17 — Session 3,
North Mississippi Medical Center, 7 p.m.
Greenville — October 22 — Session 1; October
29 — Session 2; November 5 — Session 3,
Greenville General Hospital, 8 p.m.
Session 1 — Private Care for Patients with
Tuberculosis, Dr. Guy Campbell
Surgical Practices in the Management of
Tuberculosis, Dr. Karl Stauss
Session 2 — Back Pain

Neurological Approach, Dr. Armin Haerer
Neurosurgical Approach, Dr. Robert R.
Smith

Session 3 — Modern Management of RH
Sensitization

In the Mother, Dr. Calvin Hull
In the Infant, Dr. Alfred Brann

Southwest Circuit

McComb — October 13 — Session 1, Southwest
Mississippi General Hospital, 7 p.m.
Natchez — October 20 — Session 1, Jefferson
Davis Memorial Hospital, 7:30 p.m.
Session 1 — Management of Congenital Heart
Disease, Dr. David G. Watson
Ischemic Heart Disease, Dr. Patrick
Lehan

Southeast Circuit

Pascagoula — November 10 — Session 1, Sing-
ing River Hospital, 6:30 p.m.

Session 1 — Current Trends in the Manage-
ment of Septic Shock, Dr. William A.
Neely

Management of Breast Lumps, Dr. James
Spell

Eastern Circuit

Columbus — November 24 — Session 1, The
Downtowner Motor Inn, 6:30 p.m.

JOURNAL MSMA

Session 1 — Surgical Aspects of Urinary Tract
Trauma, Dr. W. Lamar Weems
Topic to be announced, Dr. Tom Kilgore

FUTURE CALENDAR

September 11-12, 1970

Ophthalmology Seminar

September 22, 1970

Circuit Course, Tupelo

October 13, 1970

Circuit Course, McComb

October 20, 1970

Circuit Course, Tupelo
Circuit Course, Natchez

October 20-22 , 1970

Mississippi Academy of General Practice

October 22, 1970

Circuit Course, Greenville

October 29, 1970

Circuit Course, Greenville

November 2-6, 1970

Radiology Intensive Course
Electrocardiography Intensive Course

November 4, 1970

Pulmonary Seminar: The pClot That
Kills

November 5, 1970

Circuit Course, Greenville

November 9-13, 1970

Gastroenterology Intensive Course
Pediatrics Intensive Course

November 10, 1970

Circuit Course, Pascagoula

November 17, 1970

Circuit Course, Tupelo

November 24, 1970

Circuit Course, Columbus

November 30-December 4, 1970

Neurological Diseases and Stroke In-
tensive Course
Cardiology Intensive Course

December 7-11, 1970

Nephrology Intensive Course

December 7 , 1970

Circuit Course, Hattiesburg

December 11 , 1970

Gynecologic and Obstetrical Infections
Seminar

January 6, 1971

Circuit Course, Biloxi

January 7, 1971

Circuit Course, Hattiesburg

January 11-15, 1971

Neurological Diseases and Stroke In-
tensive Course

January 12, 1971

Circuit Course, McComb

January 18-22, 1971

Cancer Chemotherapy Intensive Course

February 1-5, 1971

Electrocardiography Intensive Course

February 3, 1971

Circuit Course, Gulfport

February 4, 1971

Circuit Course, Hattiesburg

February 16, 1971

Circuit Course, Natchez

February 18, 1971

Neurology Seminar

February 23, 1971

Circuit Course, Columbus

March 1-5, 1971

Gastroenterology Intensive Course

March 3, 1971

Circuit Course, Bay St. Louis

March 4, 1971

Circuit Course, Hattiesburg

March 5, 1971

Renal Seminar

March 8-12, 1971

Nephrology Intensive Course
Cardiology Intensive Course

March 9, 1971

Circuit Course, Meridian

April 5-9, 1971

Pediatrics Intensive Course

April 6, 1971

Circuit Course, Meridian

April 13, 1971

Circuit Course, McComb

April 19-23, 1971

Radiology Intensive Course

OCTOBER 1970

567

POSTGRADUATE / Continued

April 20, 1971

Circuit Course, Natchez

April 27, 1971

Circuit Course, Columbus

May 3-6, 1971

Mississippi State Medical Association
May 11, 1971

Circuit Course, Meridian

Barry, Esther Garcia, Pascagoula. Born San-
ta Clara, Cuba, Dec. 21, 1926; M.D. University
of Havana School of Medicine, Cuba 1953; In-
terned Sacred Heart Hospital, Pensacola, Florida,
one year; Pediatrics residency, Mobile General
Hospital, Mobile, Alabama July 195 6- June 1957
and July 1967-June 1969; elected Aug. 1970,
Singing River Medical Society.

Humphrey, Charles Roosevelt, Jr., Fayette,
Born Egypt, Miss. April 24, 1932; M.D., Meharry
Medical College School of Medicine, Nashville,
Tenn., 1961; Interned George W. Hubbard Hos-
pital, Nashville, Tenn., one year; elected August
1970, Adams County Medical Society.

Pandey, Shanti, Fayette. Born India Sept. 3,
1935; M.D. Prince of Wales Medical College
Patna University, Patna, Bihar, 1958; Interned,
Same, one year; Master of Surgery in Ob-Gyn,
Same, Sept. 8, 1965-Dec. 1, 1967; elected August
1970, Adams County Medical Society.

Vesa, Antonio Gregori, Biloxi. Born Cuba
Feb. 16, 1915; M.D. University of Havana
School of Medicine, Cuba, 1943; Interned Calixto
Garcia Hospital, Havana, Cuba, one year; Oph-
thalmology residency Cuba 1947-1949; Oph-
thalmology residency 1961-1962; Ophthalmology
residency Cobb Memorial Hospital, Phenix City,
Ala., 1963-1964; elected August 1970, Coast
Counties Medical Society.

Towns, Sherrod Ross, M.D., Vanderbilt Uni-
versity School of Medicine, Nashville, Tennessee,
1904; died August 10, 1970, age 94.

Genetics Course
Slated for November

Genetics for the internist will be the topic of
an American College of Physicians postgraduate
course scheduled for Nov. 11-13, 1970, at the
New York Hospital-Cornell Medical Center, New
York City.

Co-directors are Drs. Alexander G. Bearn and
E. Lovell Becker. Minimum number of regis-
trants is 35 and the maximum is 100.

The course will emphasize the clinical aspects
of human genetics particularly pertinent for the
practicing internist. The course will comprise
formal lectures, panel discussion, case presenta-
tions and question and answer periods.

Heart Association
Plans Scientific Meet

Forms to register for the 43rd annual Scienti-
fic Sessions of the American Heart Association
may now be obtained through the Association’s
National Office or from local Heart Associations.

The meeting is being held from Thursday morn-
ing, Nov. 12 through Sunday noon, Nov. 15 in
Convention Hall, Atlantic City, N. J. Seven pro-
grams on Clinical Cardiology and concurrent ses-
sions on various phases of cardiovascular research
and medicine, will be presented. In addition, the
meeting will feature lectures, panels symposia
and the screening of recently produced cardio-
vascular films.

On Thursday evening, Nov. 12, a series of
Cardiovascular Conferences will be devoted to
small group discussion of CV problems. A special
“Meet the Expert” session will be held on Satur-
day evening, Nov. 14 for talks on a variety of
cardiovascular topics.

As in the past, scientific and industrial exhibits
will be displayed throughout the meetings. In-
dustrial exhibit space may be obtained through
Steven K. Herlitz, Inc., 850 Third Ave., New
York, N. Y. 10022.

568

JOURNAL MSM A

New, Beefed-Up Legislative Program
Will Ask Active Aid of All Members

“Give a day for MSMA!”

This is the appeal to every member in behalf
of the new and expanded legislative program
adopted by the House of Delegates, reviewed by
the Board of Trustees, and now being implement-
ed by the Council on Legislation.

Dr. C. D. Taylor, Jr., of Pass Christian,
chairman of the legislative body, said that the
first objective of the new program is involvement
of every association member.

“The most serious business before our last an-
nual session,” Dr. Taylor observed, “was the
series of legislative crises we experienced during
the 1970 Regular Session.

“It is a matter of physician-to-legislator com-
munication, and many senators and representa-
tives have made it clear that they wish to hear
from hometown physicians on a week-to-week
basis.”

He said that the “Give a Day” program, for-
mally approved by the House of Delegates, will
ask each association member to devote one day —
not a Saturday or Sunday — to work in behalf of
the association’s legislative program.

Dr. Taylor said that “only 65 to 70 physicians
can serve as Doctors of the Day in our Emer-
gency Medical Care Unit in the Capitol which is
open during each working day of the legislature
in regular and special sessions. The association
employs a full-time R.N. in the unit.

“But we intend to call on members to visit
with their own county delegations of senators
and representatives, make speeches before civic
and service clubs, meet with other associations
having a common interest in health and medical
legislation, and do special tasks in the legislative
field.”

Dr. Taylor said that the Council on Legislation
had just held its fall meeting at Jackson and
that plans are well along toward putting the pro-
gram into effect.

The council also received referrals from the
House of Delegates on legislative items growing

out of resolutions and reports adopted. Among
these are:

— Amendments to the state’s archaic abortion
law to permit the procedure when the health as
well as the life of the patient is at stake, when the
pregnancy results from rape or incest, or when
there is probability that the infant will be born
deformed.

— A limited licensure law for foreign medical
graduates found competent after searching exam-
ination and who work in state institutions. They
would not practice privately.

— Establishing of statutory standards for all
practitioners who hold themselves out to diagnose
and treat disease, requiring all to meet M.D.
standards.

— Support of the University of Mississippi
School of Medicine in enlarging classes to in-
crease the supply of physicians.

— Continuation of the emergency medical
helicopter airlift service, Project CARE-SOM.

Dr. Taylor said that the new program will
also include a weekly legislative bulletin for
every member of the association.

“We intend to have a fully informed member-
ship on health and medical legislation,” he em-
phasized.

He said that a staff executive from association
headquarters will be available at the Capitol daily.

The council reviewed the adverse series of pro-
posals last session which prompted formulation of
the expanded program, Among these issues were
chiropractic licensure, dilution of the State Board
of Health in one measure and another to abolish
it, malpractice action awards without the need for
corroborative medical evidence, licensure amend-
ments, and proposals inimical to practice and pa-
tient care.

Dr. Taylor said that the council will meet
monthly during the 1970 Regular Session of the
Legislature, periodically reviewing the associa-
tion’s program.

5 69

OCTOBER 1970

ORGANIZATION / Continued

Jerry R. Adkins of Biloxi announces the asso-
ciation of Ray L. Wesson in the practice of gen-
eral and thoracic surgery at The Surgical Clinic,

1 1 60 West Howard Avenue.

Raymond A. Allen, formerly of Phoenix, Ariz.,
has been appointed chief of pathology at St.
Dominic-Jackson Memorial Hospital in Jackson.

S. Lamar Bailey and Paul E. Mink of Kos-
ciusko have been commended by President Rich-
ard M. Nixon for work they have done in be-
half of the county draft board as medical advisors.

The Department of Medicine at the University of
Mississippi Medical Center at Jackson has an-
nounced the following promotions: Thomas M.
Blake from associate professor to professor;
Marvin H. Jeter from instructor and director of
outpatient services to assistant professor and hos-
pital assistant director for ambulatory services;
Kenneth R. Bennett from instructor to assist-
ant professor and director of RMP coronary
care facility and training program; and William
R. Lockwood from assistant to associate profes-
sor.

Julian E. Boggess of Columbus announces the
limiting of his practice to the eye. His office is
located at 1124 Main Street.

E. V. Bramlett of Batesville has received a 20-
year service and appreciation award from Selec-
tive Service Board No. 40. Dr. Bramlett served
as local board medical advisor.

H. B. Cottrell of Jackson, the State Health
Officer, was guest speaker at a recent meeting of
the Forest Rotary Club.

Karl W. Hatten of Vicksburg has been named
District Two Heart Association chairman.

J. W. Hollingsworth of Meadville was recently
honored with a certificate noting his 15 years of
service as a member of the Franklin County
Draft Board.

George T. Kimbrough of Hattiesburg announces
the removal of his offices for the practice of pe-
diatrics to the Medical Arts Building at 405 South
28th Avenue.

Dewey H. Lane of Pascagoula is serving as
chairman of the Mississippi Economic Council
Special Committee on Public Education which
sponsored a “Stay in School” campaign in Au-
gust and September.

William E. Lotterhos of Jackson and Walter
Crawford of Tylertown represented Mississippi
at the Fourth World Conference on General
Practice in Chicago. Dr. Lotterhos was one of
two delegates from the United States, served as
chairman of one section, and was speaker at an-
other.

Charles Miller Murry, Jr., of Oxford has
been elected to the Wood Junior College Board
of Trustees.

James A. Pittman, formerly chief of surgery
at Patrick Air Force Base, Fla., has joined the
Rush Medical Group in Meridian.

Allen M. Read of Natchez announces the asso-
ciation of David R. Steckler in the practice of
pathology.

William H. Rosenblatt and James C. Hays
of Jackson wish to announce the association of
James L. Crosthwait in the practice of cardi-
ology at 1 1 57 N. State Street.

Thomas G. Ross of Jackson accompanied a group
of Methodist youth on a 12 day work mission in
Mexico where he held a medical clinic. The mis-
sion was sponsored by the Youth Ministry Coun-
cil of the Galloway Memorial United Methodist
Church.

J. D. Rutherford, III, announces the opening
of his office for general practice at Colonial Plaza
Building No. 2, Highway 90, Bay St. Louis.

Thomas H. Simmons of Leland has been ap-
pointed to serve as a member of the Leland
school board until an election can be held in
March, 1 97 1 , to fill an unexpired term.

William A. Sweat, Robert R. Gatling, and
William F. Kliesch, all of Jackson, have been
appointed to the staff of the Jackson Veterans’
Administration Center.

J. T. Thompson of Moss Point was elected a di-
rector of the Pascagoula-Moss Point Area Cham-
ber of Commerce at the annual membership meet-
ing. He will serve a three year term.

Guy T. Vise, Jr., of Meridian was one of five
American and Canadian orthopedic surgery resi-
dents selected as North American Travelling Fel-
lows of the American Orthopedic Association. He
toured for five weeks visiting a total of 40 major

5 70

JOURNAL MSM A

medical institutions in American and Canadian
cities.

Fred Wells, Jr., of Greenville has completed a
24-week course in aerospace medicine and has
received his Naval flight surgeon wings at the
Pensacola Naval Air Station.

Stoney Williamson announces the opening of
his offices in Suite 106, The Medical Plaza in
Hattiesburg, for the practice of ophthalmology.

David T. Wilson of Louisville announces the
association of Anse B. Howard, III for the
practice of general medicine and surgery at the
Medical Center.

EENT Specialists to
Meet in Las Vegas

More than 9,000 medical-surgical specialists
in eye, ear, nose, and throat will assemble in Las
Vegas, Nev., Oct. 5-9 for the 75th Annual Ses-
sion of the American Academy of Ophthalmology
and Otolaryngology.

Opening the meeting at the Convention Center
will be the nation’s top health official, Dr. Roger
O. Egeberg, Assistant Secretary for Health and
Scientific Affairs, HEW. He will address the Joint
Scientific Session on Monday, Oct. 5.

The week’s activities will be filled with ten
scientific sessions, and with 485 instructional
courses. In addition, the North Exhibit hall of
the new Center will house scientific and commer-
cial exhibits.

Ophthalmology research reports to be presented
will include those on complications of surgery for
retinal detachment, use of lasers to diagnose eye
diseases, suitability of cadaver eyes for trans-
plants, acquired color blindness, the use of soft
contact lenses in certain eye conditions, and in
chemical treatment of melanoma of the eye.

Otolaryngology research reports will include
those on ear drum and ossicle transplants, the
dizzying-and-ear-ringing disorder known as
Meniere’s Disease, congenital deafness, facial
paralysis (Bell’s Palsy), a special form of mus-
cular dystrophy which affects the eyes and throat,
and a one-stage operation for vocal rehabilitation
of the patient whose voice box has been removed
by surgery because of cancer.

A special symposium on Computer Assistance
in Health Service will be featured on Monday,
immediately after Dr. Egeberg’s speech.

The exhibits will include 61 on the eye and 17
on ear-nose-throat. Subjects include prevention of
speech problems in children with cleft palate,
scanning electron microscope views of the eye’s
Canal of Schlemm, daily variations in eye pres-
sure, effects of noise on hearing, chemical analy-
sis of conjunctival mucus and its meaning for the
wearing of contact lenses, nasal obstruction as
a cause of sudden death in infants, use of the
laser in eye refraction, use of computers in eye
refraction, occurrence of virus retinitis in kidney
transplant patients, and ultrasonic measurements
of the eye.

The least-publicized but best-attended part of
each year’s AAOO convention is its instructional
program, where the specialists learn the latest in-
formation and techniques in their fields. This
year’s courses — which run every day, morning
and afternoon — are expecially focused on the
small: microscopic and electronmicroscopic pa-
thology, and microsurgery — surgery on the eye
and middle ear performed with the aid of micro-
scopes.

President of AAOO is Dr. Jerome A. Hilger,
St. Paul, Minn. Dr. Clair M. Kos is executive
secretary-treasurer at AAOO headquarters in
Rochester, Minn. Dr. Francis L. Lederer, Chi-
cago, 1968 president of AAOO, is chairman and
coordinator of the AAOO Committee for Public
and Professional Relations.

Nov. 1 Is Deadline
for Heart Grants

November 1, 1970 is the deadline for submit-
ting applications for Grants-in-Aid to be awarded
by the American Heart Association in the fiscal
year beginning July 1, 1971.

Grants-in-Aid are made to support and ex-
pand the research activities broadly related to
cardiovascular function and disease, or to related
fundamental problems. Support is available for
all basic disciplines, such as physiology, biochem-
istry and pathology, as well as for epidemiological
and clinical investigations which bear on cardio-
vascular problems.

Limited funds are also available for support of
research in the basic science disciplines which are
independent of any apparent direct application
to the field of cardiovascular disease.

For Grants-in-Aid applications write to the Re-
search Department, American Heart Association,
44 E. 23rd Street, New York, N. Y. 10010.

OCTOBER 1970

571

ORGANIZATION / Continued

Dr. Jenkins Honored
for 50 Years of Service

Dr. W. N. Jenkins of Port Gibson was recently
honored at a reception at the Claiborne County
Hospital for his having served a half century in
the medical profession.

On behalf of the Mississippi State Medical As-
sociation, Dr. Roy M. Barnes presented him a
framed certificate as a member of the Fifty-Year
Club of the association.

The certificate read as follows: “This is to
certify that William Nathan Jenkins, M.D., having
served his patients and fellow citizens faithfully
and devotedly in the practice of medicine for
fifty years and having brought honor and credit
to the professional community and himself, has
been elected a life member of the Fifty-Year Club,
on recommendation by his component medical
society. By the Board of Trustees of the Missis-
sippi State Medical Association. This 26th day of
June, 1970.“

Dr. W. N. Jenkins received the coveted certificate
of membership in the MSMA Fifty-Year Club from
Dr. Roy Barnes of Port Gibson in special ceremonies
at Claiborne County Hospital.

E. P. Spencer, hospital administrator, present-
ed Dr. Jenkins a copy of resolutions from the
hospital board of trustees in which the board
praised him for his services as Chief of Staff of
the hospital and for his services to the community.

C. Y. Katzenmier, representing the City of
Port Gibson, presented Dr. Jenkins a silver tray
as a “gift of appreciation from the people of the
community.”

1970-71 AMA-ERF
Campaign Is Set

The 1970-71 campaign for the American Med-
ical Association Education and Research Founda-
tion will be opened in October. This was the
announcement of Dr. Raymond F. Grenfell of
Jackson, state association chairman of the Com-
mittee on AMA-ERF.

Contributions to the foundation are fully tax-
deductible, Dr. Grenfell reminded, and 100 cents
out of each dollar given goes to the purpose for
which contributed. No deductions are made for
handling or administrative costs.

Donors may earmark their gifts for a particular
medical school or foundation activity. Unear-
marked contributions go into the general founda-
tion fund which is equally divided among the
nation’s medical schools.

“No AMA-ERF funds support the former
AMA Institute for Biomedical Research,” Dr.
Grenfell noted. “The Institute was terminated by
AMA last year.

“It is to be remembered, however,” the chair-
man continued, “That Institute support was de-
rived from particular gifts for that specific pur-
pose when the project was in operation.”

As in previous years, the state medical associa-
tion is working in concert with the University
Medical Center and the Ole Miss Medical Alum-
ni Association in the 1970-71 campaign. The
partnership offers participating physicians and
Woman’s Auxiliary members several avenues
through which to make contributions.

UMC and the medical alumni association will
again make direct appeals for voluntary support,
as will the state medical association. The new
single, itemized billing statement for dues will
also permit inclusion of the physician’s AMA-
ERF gift in the single check. The amount volun-
tarily specified will be transmitted to AMA-ERF.

Remittances along with dues payments may be
earmarked for a specific medical school, if desired,
by simply noting the name of the institution on
the returned portion of the statement.

Mississippi physicians exceeded their colleagues
in Alabama, Arkansas, Louisiana, and Tennessee
last year on per capita giving, but the net amount
which went to the University Medical Center
was smaller than in 1968, the announcement said.

The association has sponsored the annual cam-
paign for voluntary support of medical education
through AMA-ERF since 1953, and the goal of
the 1970-71 campaign is to reach the highest
degree of participation and net gift to medical
education.

572

JOURNAL MSMA

Book Reviews

Handbook of Psychiatry. By Philip Solomon,
M.D. and Vernon D. Patch, M.D. 623 pages
with illustrations. Lange Medical Publishers,
1969. $7.00.

The Handbook of Psychiatry composed by ex-
cellent authors, Drs. Philip Solomon and Vernon
D. Patch, represents an extremely well integrat-
ed and well organized volume. The handbook
is quite readable and authoritative. It can serve
as an exceedingly useful reference in the field of
psychiatry.

The first six chapters make for good reading
and give helpful hints for screening interviews.
There is a good outline for mental status exam-
inations with the primary emphasis on listening
to the patient and points out that only after lis-
tening, should there be directed questions regard-
ing suicide, hallucinations, etc.

Of particular importance is the seventh chap-
ter, Differential Diagnostic Symptoms and Signs.
In this chapter there is concise understandable
meaning to much psychiatric lingo. There is also
better understanding as to how a different psy-
chiatric diagnosis can be made by different psy-
chiatrists based on symptoms that appear dom-
inant at any particular time the patient may be
seen. The symptoms listed in chapter seven can
be used as a guide toward reading the more de-
tailed description of specific neurotic, psychotic
and organic illnesses, as well as character or
personality disturbances.

There is a superficial but helpful part in psy-
chiatric treatment covering drugs, electroshock
treatments, and emergency procedures. Through-
out this volume are numerous suggestions as to
simple methods of evaluating the severity of men-
tal and/or emotional illness which could be most
helpful in giving the general practitioner useful
information as to when referrals to psychiatrists
become wise and necessary. The last two pages
of the book are a well documented, short cut to
emergency psychiatric diagnosis and management.

George M. Wilson, M.D.

The Vitreous in Clinical Ophthalmology. By
Norman S. Jaffe, M.D. 300 pages with 334 il-
lustrations. St. Louis: The C. V. Mosby Com-
pany, 1969. $32.50.

The author’s stated purpose is the compilation
of the available scientific knowledge concerning
the vitreous and the relating of this knowledge to
clinical situations. This he does quite successful-
ly. Dr. Jaffe is well qualified on this subject since
he is clinical assistant professor of ophthalmology,
University of Miami School of Medicine; chair-
man, department of ophthalmology, St. Francis
Hospital, Miami Beach; attending ophthalmolo-
gist, Mt. Sinai Hospital of Greater Miami, Fla. He
also teaches the course on the vitreous at the
American Academy of Ophthalmology and Oto-
laryngology.

Dr. Jaffe follows the usual format in present-
ing a thorough review of the embryology, anato-
my and physiology of the vitreous body. He then
proceeds to the pathology and presents an excel-
lent resume of the Irvine-Gass Syndrome and
other vitreous traction problems. There is a com-
prehensive discussion of the problems of cataract
surgery including a review of surgical techniques
designed to deal with vitreous loss at surgery and
medical and surgical methods of handling post-
operative hyaloid rupture and persistent corneal
edema. The author gives a clear review of indi-
cations and methods for vitrectomy. The role of
the vitreous in aphakic pupillary block, narrow
angle glaucoma and malignant glaucoma is
dealt with extensively, reviewing Shaffer’s work
on the posterior vitreous pool. There is a good
discussion of sclerotomy and sclerochoroidal
drainage procedures. Chapters on the vitreous in
retinal detachment are comprehensive and well
illustrated. These deal with the all too common
problems of vitreous traction and some of the
newer surgical methods for attacking traction
bands. Transfer and replacement of the vitreous
are considered.

Since the vitreous plays a vital role in diabetic
retinopathy following the preliminary stage of
aneurisms, punctate hemorrhage and hard exu-
date, there is a chapter devoted to this entity.

5 73

OCTOBER 1970

ORGANIZATION / Continued

In dealing with a subject such as this, with all
of the pathologic involvements he has covered,
Dr. Jaffe has done a commendable job of re-
viewing the world literature. There are profuse
references as well as careful consideration of the
varied opinions of several researchers. The au-
thor’s bibliography is excellent. He has used many
fine illustrations, fundus photographs and photo-
micrographs to clarify his text. This work is a
worthwhile addition to any ophthalmic library
and certainly helps fill a large gap in our knowl-
edge of an extremely important issue.

Theresa L. R. Buckley, M.D.

New Ovral Package
Has 3 -Month Supply

Wyeth Laboratories’ oral contraceptive, Ov-
ral®, is now available in a convenient “3-Pak”
package containing a three-month supply.

Designed to provide maximum convenience
for patients, the new Ovral 3-Pak also reflects
the preference of an increasing number of physi-
cians for prescribing a three-month supply of
oral contraceptives.

The 3-Pak consists of the following: a comb-
type case containing a one-month supply of Ov-
ral; two additional months’ supply; and patient
information.

In addition to the new 3-Pak, Ovral continues
to be supplied in a carton containing six single-
cycle Pilpaks™.

Coronary Care Unit
Nears Completion

Coronary care throughout Mississippi will get
a boost as specialized training programs get un-
derway at the University Medical Center, begin-
ning in October.

Funded by the Mississippi Regional Medical
Program, a six-bed coronary care unit in Uni-
versity Hospital, now under construction, will
serve as the central demonstration and training
facility for coronary care staffs across the state.

Dr. Kenneth Bennett, University CCU director
and head of the statewide coronary care unit

system project, and Mrs. Elizabeth Jackson,
nurse director, will be in charge.

Registered nurses who work in coronary care
units or in hospitals with monitoring systems have
been invited to apply for training in a series of
four-week courses on care of patients with myo-
cardial infarction and heart electrical activity
disorders. Classes are scheduled in October, 1970,
January and March, 1971. Physicians and other
members of the Mississippi health team will also
train in the unit when it is completed.

M. D. Anderson Hospital
Plans Conference

“Progress in the Rehabilitation of the Cancer
Patient” will be the subject of the 15th Annual
Clinical Conference sponsored by The University
of Texas M. D. Anderson Hospital and Tumor
Institute at Houston, Nov. 19-20, 1970.

The Shamrock-Hilton Hotel will be the site of
the two-day conference, co-sponsored by the Di-
vision of Continuing Education of the UT Grad-
uate School of Biomedical Sciences at Houston.

The conference will be the first major medical
meeting to offer an interdisciplinary approach to
rehabilitation of cancer patients. Sessions will be
devoted to problems of patients with cancer of
specific sites, problems of amputees, techniques in
nursing and physical therapy and aspects of
psychological and social adjustments and voca-
tional training.

Speakers representing about 20 medical and
educational institutions and organizations, as well
as government agencies, will participate in the
program, according to Drs. John E. Healey, Jr.,
chairman, and Joe B. Drane, co-chairman.

The Heath Memorial Award will be presented
on Nov. 19. Established in 1966, the award is
conferred annually on a physician or scientist
who has made an outstanding contribution to the
better care of cancer patients through clinical
application of basic research knowledge.

On Nov. 21 a symposium on bone tumors will
be held in conjunction with the Clinical Con-
ference. The Anderson department of anatomical
pathology and the Texas Society of Pathologists
will host the meeting, beginning at 9 a.m. in
M. D. Anderson Hospital auditorium in the Tex-
as Medical Center.

Pathologic, radiologic and surgical aspects of
bone tumors will be discussed by a panel mod-
erated by Dr. Paul Lund.

574

JOURNAL MSM A

MPAC

AMPAC

give you IMPACT, doctor!

But make it a mutual impact, doctor, because your PAC
needs you and you need your PAC. Both AMPAC and
each of the 50 state PAC’s are voluntary, nonprofit, un-
incorporated, autonomous groups whose members are
physicians, their wives, and others in allied professions.
Every group is bipartisan, bound by no party label. The
voting record, platform, and program of a candidate —
not his party — is what the PAC considers.

The basic purpose is twofold: To educate in political
affairs and to provide a means through which the physi-
cian-citizen can effectively make his voice heard in the po-
litical arena. MPAC is medically oriented and medically
directed by a 10 member board consisting of nine physi-
cians and a Woman’s Auxiliary representative.

With the elections behind, MPAC is looking ahead to
1971 when there will be a job to do. Make your voice
count by sending your dues today, $10 for MPAC and
$10 for AMPAC. Better send dues for your wife, too.

MISSISSIPPI MEDICAL
POLITICAL ACTION
COMMITTEE

575

OCTOBER 1970

ORGANIZATION / Continued

Magazine Aims At
Exceptional Parent

The Exceptional Parent, a new magazine, is
announced for distribution beginning in Septem-
ber, by the Psy-Ed Corporation, publishers. The
Exceptional Parent, unique among education-
al and professional publications, will aim “to
provide practical help for the parents of children
with disabilities.” It will combine the knowledge
of experts with the day-to-day experiences of lay-
men.

The magazine will deal with many issues that
affect the exceptional child and will cover such
topics as the role of the family, the nature and role
of the various professional groups with whom
the family is apt to come in contact, and the ways
in which certain aids can be helpful. Information
will be easily understandable, practical as well as
theoretical. The Exceptional Parent will also
provide a means for parents to exchange ideas,
share concerns, and discover new approaches to
common problems.

The founders and editors of The Exceptional
Parent are three professional colleagues who
are practicing psychologists and university profes-
sors: Lewis Klebanoff, Stanley Klein and Max-
well Schleifer.

Dr. Klebanoff is Director of the Massachusetts
Department of Mental Health-Boston University
School of Education Joint Center for Develop-
mental Research, a lecturer at Harvard Medical
School, and an advisor to the United States Office
of Education on early childhood education for the
handicapped. He was instrumental in the estab-
lishment in Massachusetts of the first statewide
preschool program for children with developmen-
tal disabilities.

Dr. Klein is an Assistant Professor of Psychol-
ogy at the University of Massachusetts at Boston
and a former member of the Psychiatry faculty
at the Boston University School of Medicine. He
is Secretary of the Board of Trustees of the Mas-
sachusetts Association for Retarded Children Re-
tardate Trust and a member of the Professional
Advisory Committee of United Cerebral Palsy of
Greater Boston. Formerly, Dr. Klein was heard
daily on CBS radio in Boston on a program
“Child Psychologist — At your Service.”

Dr. Schleifer is an Associate Professor at the
University of Massachusetts at Boston and Execu-
tive Director of the Warren Center for Emotion-

ally Disturbed Children. He is the former Chief
Psychologist at the Douglas A. Thom Clinic for
Children and the former Field Unit Director
for the Judge Baker Guidance Center. He has
written papers on the role of the family in the life
of the educationally disabled child and alterna-
tives to residential care for emotionally and intel-
lectually handicapped children.

Charter subscriptions to The Exceptional
Parent, which will be distributed nationally, are
$6.00 a year. Further information may be ob-
tained by writing The Exceptional Parent,
Box 45, Newtonville, Mass. 02160.

Neurology Seminar
for Internists Set

The American College of Physicians will spon-
sor a postgraduate course, “Neurologic Aspects of
Internal Medicine,” Oct. 20-23, 1970, at Duke
University Medical Center, Durham, N. C.

Dr. Stanley H. Appel is director and Dr. Al-
bert Heyman is co-director. There must be a min-
imum of 50 registrants and no more than 100.
Preference will be given to members of the
College.

The overall emphasis in the course will be on
the therapeutic approaches to the problems of
neurologic dysfunction. The main teaching modes
will be small discussion groups, panel discussion,
and case presentations.

Chest Physicians
Announce Meeting

The Southern Chapter of the American Col-
lege of Chest Physicians will hold its annual
scientific session on Nov. 16, 1970 at the Civic
Auditorium, Dallas, Texas.

An interdisciplinary faculty will provide basic
information on the principles of circulation and
respiration and the application of this information
to patient care.

Dr. Russell M. Nelson, Salt Lake City, Pro-
fessor of Thoracic Surgery, Utah School of Medi-
cine, is the 17th Paul A. Turner Memorial Lec-
turer. Dr. Nelson will discuss application of com-
puters to medicine and surgery of the chest.

5 76

JOURNAL MSM A

MEETINGS

<

NATIONAL AND REGIONAL

American Medical Association, Clinical Conven-
tion, Nov. 29-Dec. 2, 1970, Boston. Annual
Convention, June 20-24, 1971, Atlantic City.
Ernest B. Howard, Executive Vice President,
535 N. Dearborn St., Chicago, 111. 60610.

Southern Medical Association, 64th Annual
Meeting, Nov. 16-19, 1970, Dallas. Mr. Rob-
ert F. Butts, Executive Director, 2601 High-
land Ave., Birmingham, Ala. 35205.

STATE AND LOCAL

Mississippi State Medical Association, 103rd An-
nual Session, May 3-6, 1971, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Mississippi Academy of General Practice, Annual
Assembly, Oct. 20-22, 1970, Biloxi. Miss Lou-
ise Lacey, Executive Secretary, P.O. Box 1435,
Jackson.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday,
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Walter H. Rose, 122 E. Baker
St., Indianola 38751, President.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-

taurant, Hernando. Malcolm D. Baxter, Jr.,
Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday,
February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, February, April, June, August, October,
and December, Eola Hotel Roof, Natchez.
Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October. Cherie Friedman,
1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.
J. M. Howell, 139 Kirkwood St., Picayune,
Secretary.

Prairie Medical Society, Second Tuesday, March,
June, September, and December. A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday,
January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,
Pascagoula, Secretary.

South Central Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,
Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.
W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m.. Old Southern Tea Room, Vicksburg.
Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

OCTOBER 1970

577

Drug research
rives me the tools
that save fives."

A family doctor looks at new de-
velopments in the pharmaceutical
industry. And he speculates on the
future.

When I look back at some of my
old records, I’m constantly re-
minded of the changes that have
come about in medicine just during
the past twenty-five years. Some of
the diseases I treated and prayed
over in the ’40’s are found mostly
in medical history books now.

Thanks to drug research and de-
velopment, we’ve made substantial
gains in the control of cardiovas-
cular disease, diabetes, malaria,
mental illness, strep and staph in-
fections, meningitis and a long list
of ailments. It seems like only yes-
terday when a diagnosis of pneu-
monia was almost the kiss of death.
Now, w'th modern medical tech-
niques and drug therapy, we can
offer some real help.

My records on polio, influenza
and measles show an unbelievable
trend for the better. New vaccines

have reduced the toll of these age-
old threats dramatically. And I see
patients in pain from crippling ar-
thritis helped with new medicinals
unknown just a few years ago.

I hear questions about the three
billion or so dollars spent by the
drug industry in research during
the past ten years . . . working
on new and better drug products.
It does seem like quite a bit of
money to spend, and I realize some
of it goes into dead ends. That’s
the problem with research, any re-
search . . . you often don’t know
where you’re going until you get
there. I want all the tools I can get
to help my patients. I want more
drugs and more effective druqs. If
they mean less pain, longer lives
and more productive careers for
those I treat . . . well, that’s what
really counts.

Another point of view . . .
Pharmaceutical Manufacturers
Association, 1155 Fifteenth Street,
N.W., Washington, D.C. 20005.

This advertisement has been reaching consumers thru
THE ATLANTIC, FAMILY HEALTH, HARPER'S MAGAZINE, NEWSWEEK,
SATURDAY REVIEW, TIME and U.S. NEWS & WORLD REPORT

Taste!

Dicarbosi

ANTACID

Your ulcer patients and
others will love it. Specify
DICARBOSIL 144's-144 tab-
lets in 1 2 rolls.

ARCH LABORATORIES

11 319 South Fourth Street. St. Louis. Missouri 63102

Has the diagnostic equipment in your office kept
pace with your own knowledge of new drugs,
medicines and technics?

Write us for full details on the Burdick EK-IV
Dual-Speed Electrocardiograph.

KAY SURGICAL INC.

663 North State St. • Jackson, Miss. 39201

Index to Advertisers

AMPAC, MPAC 575

Arch Laboratories 579

Becton Dickinson and Company 540A. 540B

Bio-Dynamics, Inc 10A, 10B

Blue Cross-Blue Shield 7

Breon Laboratories 8

Burroughs-Wellcome 560B

Campbell Soup Company 560A

The Carlton Corporation 11

Hill Crest Hospital 6

Hynson, Westcott and Dunning 3

Kay Surgical 579

Lederle Laboratories 4, 12

Leonard Wright Sanatorium 10

Eli Lilly and Company front cover, 18

Merck, Sharp and Dohme 562. 563, 564

William S. Merrell Company second cover

National Drug Company 536A, 536B, 572A, 572B

Pharmaceutical Manufacturers Association ...... 578

William P. Poythress and Company 568A

A. H. Robins Company 14, 14A, 14B

Roche Laboratories

16, 17, 568B, 568C, 568D, fourth cover

G. D. Searle Company 548, 549

Smith Kline and French Laboratories 15

The Stuart Company 538, 539

Thomas Yates and Company third cover

OCTOBER 1970

579

Physicians are serving on governing boards of half of 976 short-
term, nonfederal hospitals recently surveyed by AMA Council on
Medical Service. In each instance, survey turned up good relatio
between medical staff and hospital trustees on management problem
and liaison policies. Virtually every state medical association,
Mississippi included, aAIa, AAGP, American College of Surgeons, an
even Joint Commission on Accreditation of Hospitals support move.

Drug procurement policies of government agencies got a going-over
by Sen. Gaylord kelson (I). ,Wis. ) and his monopoly subcommittee.
Investigation queried Department of Defense, U.S. Public Health
Service, and medical arm of Office of Economic Opportunity. Thru
of inquiry was emphasis on cheapest generic agents available. DO
argued for quality mini mums , stating that armed forces have drugs
around the world in highly adverse climatic conditions.

Special emergency radio service licenses were authorized by Peder
Communications Commission for local and state medical societies a
for schools of medicine in recent ruling. Differing from citizen
band licenses, emergency frequencies would tie medical care sourc'
into networks for service in disasters and other critical public
needs. Use of frequencies would be limited to messages pertainin,
to "safety of life and property" and medical duties of licensees.

Removal of all tax discrimination against the professional self-
employed has been announced as an objective of Nixon administrate
and Internal Revenue Service. Not altogether altruistic, move se<
to eliminate need and purpose of professional corporations by per-
mitting equal tax treatment, for example, of M. D. *s and corporate
executives. One part of proposal, almost unbelievable, would be
maximum of 50 per cent tax ceiling on earned professional income.

Explanation of $40 annual AMA dues increase, directed by House of
Delegates at Chicago last June, has grown to major communications
campaign. Series of articles in American Medical News and special
mailings to state association leadership groups are weekly projec
AMA Board of Trustees initially proposed upping dues to $150 , but
delegates at Chicago pared increase to $110 from $70 previous lev
New increase is effective for 1971 with fall billings.

Volume XI
Number 11

November 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary-T reasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. Cody Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

CONTENTS

ORIGINAL PAPERS

Amputations in Patients
with Peripheral Vascular

Disease 581 Richard Warren, M.D.

Surgical Emergencies of

the Newborn 585 Richard C. Miller,
M.D.

SPECIAL ARTICLES

Youth and Drugs 595 Carl E. Guernsey,

LL.B.

Radiologic Seminar Cl
Roentgen Changes in the
Sella Turcica in Pituitary

Tumors 600 Lyndon M. Conley,
M.D.

EDITORIALS

Mississippi Peer Review:

The Practicing M.D.’s

Own Plan 603

Be Sure to Answer NORC’s

Call 605

The Passing of the Panama 606

Bloody Tort: Liability
Without Negligence 607

Sen. Eastland Helps the

Chiropractors 607

Masters of our House

Care Cost Study
End of an Era

Dangerous Doctrine

Request to Reconsider

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

THIS MONTH

The President Speaking 602 ‘A Busted Play?’

Medical Organization 615 CHP Study Would

Consolidate State
Agencies and Abolish
Board of Health

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR NOVEMBER 1970

Dr. Chafetz Appointed
Acting Director

Appointment of Dr. Morris E. Chafetz as Act-
ing Director of the newly established Division
of Alcohol Abuse and Alcoholism of the National
Institute of Mental Health, Health Services and
Mental Health Administration, is announced by
Dr. Bertram S. Brown, Institute Director.

“The establishment of this Division,” accord-
ing to Dr. Brown, “signifies the intensified effort
which the National Institute of Mental Health
will undertake in the coming months and years to
reduce the terrible toll which alcohol abuse and
addiction continue to exact from our society. The
programs of the Division will advance the day
when we can fully understand and treat alcohol-
ism, and prevent the misuse of alcoholic bever-
ages through education and other techniques.

Dr. Chafetz is presently Director of Clinical
Psychiatric Services of Massachusetts General
Hospital, and Associate Clinical Professor of
Psychiatry, Harvard Medical School. From 1957
to 1968 he was Director of the Hospital’s Alcohol
Clinic and from 1961 to 1968 Director of the
Acute Psychiatric Services there. He has been
active in alcoholism research and training through-
out his career and has served on numerous al-

coholism advisory groups at the national, state
and local levels.

Establishment of the new division within
NIMH was announced recently by Dr. Roger
O. Egeberg, Assistant Secretary for Health and
Scientific Affairs, HEW. Its functions include
planning and development of programs of re-
search, training, community services, and public
education for prevention and control of alcohol-
ism; conduct and support of research on the bio-
logical, environmental, and social causes of al-
cohol abuse and alcoholism; support of training of
professional and para-professional personnel in
alcoholism prevention and control; support of the
development of community facilities and services
for alcoholics and other problem drinkers; and
collaboration with other Federal agencies, na-
tional, State, and local organizations, and vol-
untary groups to facilitate and extend programs
for the prevention of alcoholism and for the care,
treatment, and rehabilitation of alcoholics.

The new division incorporates and absorbs the
NIMH National Center for Prevention and Con-
trol of Alcoholism, which was established at the
Institute in 1966.

Dr. Chafetz received his B.S. degree from Tufts
College in 1944 and his M.D. from Tufts Medical
School in 1948. He served his internship at the
U. S. Marine Hospital, Detroit, Michigan.

HOSPITAL

Hill Crest Foundation, Inc.

7 000 5TH AVENUE SOUTH
Box 2896,

Birmingham, Alabama 35212
Phone: 205-836-7201

A patient centered
non-profit hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 45 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James K. Ward, M.D., F.A.P.A.

CLINICAL DIRECTOR:

Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PRI-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL;

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

C/iest

HOSPITAL

BIRMINGHAM, ALABAMA

IL

November 1970

r Doctor:

sissippi's restrictive abortion law has been attacked on consti-
iona2 founds of vagueness and invasion of the mother fs ri^itsT
t before state Supreme Court is on appeal by a Vicksburg woman
vie ted of illegal abortion and sentenced to 10 years. Basis of
; eal is almost identical to that applied in Wisconsin and other
tes , now before U.S. Supreme Court.

Also at issue is state's invasion of right to pregnancy
interruption without compelling public necessity. Mis-
sissippi statute permits abortion by M.f). only when life
of patient is endangered or when the pregnancy results
from rape. MSMA seeks liberalization for medical reasons.

sident Nixon *s welfare reform plan took a shellacking at hands
Senate Finance Committee, quasning proposal 14-to-l. Measure,
led Family Assistance flan and "Workfare," guarantees minimum
ome of Si, 600 annually and would increase welfare rolls to 24
lion from present 10.4 million. In Mississippi, administration
n would up rolls to 806,000 from present 211,000, 282 per cent.

professional liability insurance picture darkened with announce-
t that AilA program may have to be abandoned for want of a carrier,
otiations with CNA Corp. are stalled by carrier reluctance to
ume risks. Program, if and when implemented, would be of little
efit to Mississippi which has fourth lowest premium rate in U.S.

. seeks help for states with premium levels up to $15,000 per year.

t 1-A Medicare deductible and co-ipay for hospitalization goes
again on J an . 1,1971. the third in er e as e since 1 9 6 6 ♦ Admis-
n deductible will be $60, up from present $52, and co-pay from
t to 90th days will be $15 per day. Lifetime reserve co-pay zooms
$30 per day, while daily co-pay for extended care facility rises
$7.50 for 21st through 100th days.

ly bird dues payments, under new service to members permitting
check to do the job, will establish 1976 income tax deductions,
tern eases burden of billing and accounting from component medical
ieties and assures records accuracy. Because staff is doing work
h no additional personnel, members are asked to respond now before
iislature and annual session work take priority over billing service.

THE JOURNAL FOR NOVEMBER 1970

1 0

Mr. Parish Will
Head Blue Shield

Ned F. Parish, executive vice president of the
National Association of Blue Shield Plans
(NABSP), has been designated to become presi-
dent of the National Association of Blue Shield
Plans when John W. Castellucci retires next year.

In an announcement released from Chicago
headquarters, Dr. Ira C. Layton, of Kansas City,
chairman of the National Association of Blue
Shield Plans, said:

“By designating Mr. Parish at this time as the
one who will succeed Mr. Castellucci as president
when he retires on Nov. 1, 1971, we will assure
the Association of continuity in our top manage-
ment.”

Castellucci, who recommended the need for a
plan of succession, said:

“We are facing many critical issues in health
care financing. It is essential that we have a
strong and consistent approach to meeting them,
and Ned Parish will be able to provide the
needed administrative leadership.”

Parish, an outstanding administrator in the
health care prepayment field for more than a

quarter century, has been executive vice presi-
dent of the Association since 1967.

Castellucci has been chief executive officer of
NABSP since 1955. At that time Blue Shield
Plans covered 34 million persons.

Today, the 73 Blue Shield Plans in the U. S.
and Puerto Rico serve 79 million persons under
private and government programs.

Syntex Introduces
Roll-top Applicator

Syntex Laboratories, Inc. has introduced a new
concept in pharmaceutical packaging, a roll-top
applicator, for its dematologic product Synalar
Solution 0.01 per cent (fluocinolone acetonide).

The new roll-top applicator will provide an
easier method of applying the topical corticoste-
roid in layered therapy and diseases with wide-
spread lesions. Dermatologists will find the ap-
plicator useful in both atopic and contact derma-
titis.

Syntex Laboratories is the U. S. subsidiary of
Syntex Corporation and is involved in the de-
velopment, production and marketing of pharma-
ceutical and animal health products.

LEONARD WRIGHT SANATORIUM

BYHALIA, MISSISSIPPI 3861 1 TELEPHONE A/C 601, 838-2162

LEONARD D. WRIGHT. SR., B.S., M.D., PSYCHIATRY

Established in 1948. Specializing in the treatment of ALCO-
HOLISM and DRUG ADDICTIONS with a capacity limited
to insure individual treatment. Only voluntary admissions ac-
cepted.

Located 25 miles S. E. of Memphis-Highway 78 on 20 acres
of beautifully landscaped grounds sufficiently removed to
provide restful surroundings.

The Sanatorium is approved by The Commission on Hospital
Care in the State of Mississippi.

MISSISSIPPI STATE MEDICAL ASSOCIATION

Arizona Cardiac
Symposium Scheduled

The Arizona Heart Association has scheduled
its 14th Annual Cardiac Symposium for Jan.
22-24, 1971. The meeting will be held at the
Arizona Biltmore Hotel in Phoenix.

Guest speakers include Drs. Roman DeSanctis,
Joseph Perloff, Gilbert Blount, and Rene
Fabalero.

For further information, write Arizona Heart
Association, 1720 McDowell Road, Phoenix, Ari-
zona 85006.

New Treatment
For Resistant Gonorrhea

A treatment program that can cure a high per-
centage of even supposedly “resistant” strains of
gonorrhea, is reported in a new scientific exhibit
being shown at the annual meeting of the Ameri-
can Academy of General Practice in the Civic
Auditorium.

The study, conducted by Dr. Morton Nelson,
Assistant Health Officer in the Alameda County
Health Department, Oakland, Calif., states that
gonorrhea is now number one among reportable
communicable diseases, with two million cases —
approximately one per hundred persons — esti-
mated for 1969.

Dr. Nelson's report notes, “Though gonorrhea
is epidemic, there exists no systematic national
program to attack the problem.” And, “Treat-
ment failures using previously proven schedules
are being reported from around the country, de-
scribing N. gonorrhea "resistant to penicillin.’ ”

The study presents experience with rapid-
acting aqueous procaine penicillin (APP), used
in treating strains of N. gonorrhea whose “re-
sistance” has been attributed to undertreatment
by ( 1 ) infected “hostesses” around military bases
in Asian countries who self-treat with subcura-
tive oral antibiotics, and (2) clinicians who em-
ploy sub-bactericidal dosage levels of penicillin.

Dr. Nelson’s report concludes:

(1) “At increased dosages of fast-acting peni-
cillin (APP) practically all strains — even the sup-
posedly ‘resistant’ ones — are susceptible.”

(2) “The cure rates 98 per cent (males) —
100 per cent (females) with the 4.8 million unit
dose of APP are unquestionably encouraging."

(3) “Nevertheless, the pattern of microbial
resistance is constantly changing. It is imperative
that a high enough dose be employed to keep
those less susceptible strains from increasing or
mutating to more virulent ones.”

1 1

Mississippian Joins
USP Staff

Kenneth N. Barker has been appointed to the
staff of The United States Pharmacopeial Con-
vention in the newly created position of Director
of Administrative Research.

According to U.S.P.C. Executive Director, Wil-
liam M. Heller, Barker’s long-range research will
be in areas of drug utilization that relate to the
U.S.P. responsibilities of selecting those drugs
best established medically, providing pharmaceuti-
cal quality standards, and encouraging and edu-
cating health practitioners in using them. His
immediate assignment will be in planning the
new systems and facilities needed for the ex-
panded activities of the U.S.P.C. organization, a
national consortium of colleges and national and
state organizations of medicine and pharmacy.

As Project Director of Drug Systems Research,
a multidisciplinary research group organized first
at the University of Arkansas and later at the
University of Mississippi, Barker developed a
methodology for measuring the incidence of medi-
cation errors in hospitals and conducted pioneer
research in the use of automated patient records
and unit-dose packages of drugs to improve hos-
pital medication systems. His recent research has
concentrated on the utilization of pharmists’
time and skills in small hospitals.

Mr. Barker received his B.S. and M.S. degrees
in pharmacy from the University of Florida and
expects to receive his Ph.D. degree in pharmacy
administration from the University of Mississippi
in 1971. He has worked as a community and
hospital pharmacist and taught hospital pharmacy
at the University of Mississippi.

His consultant activities have included such
companies as Wm. S. Merrell, I.B.M., Brewer
Pharmacal Engineering, Sherwood Medical In-
dustries, and several university and non-university
hospitals. He is Consultant on Hospital Pharmacy
Facilities Design to the University of Mississippi
School of Pharmacy and is currently involved as
the editor of the forthcoming U.S.P.H.S. manual
on planning hospital pharmacy facilities.

In addition to articles in hospital, pharmacy,
and nursing journals, Mr. Barker has co-authored
several books and reports.

Mr. Barker is a member of the American
Pharmaceutical Association, the American Society
of Hospital Pharmacists, and the Rho Chi Society.

It’s available because of Medicentei

Someone
acutely ill
needs this

Because of Medicenter, this hospital bed can be used
by someone who needs it. That’s what Medicenter is
all about. A recuperative care facility specializing in the
needs of patients who no longer require the intensive care
of a general hospital and who are on the road to recovery.

But that’s only part of the Medicenter story . . . Beauti-
fully carpeted and draped patient rooms, tasty foods, rec-
reation facilities, physical and inhalation therapy are
just a few of many luxurious health care features that
make recovery in the Medicenter as pleasant and rapid

as possible. The Medicenter is within minutes of a<
care facilities. A professional medical staff supervi
all recuperative care under the direct orders of each j
tient’s personal physician. Room rates are nominal
about one-half the cost of general hospitals. And the,
a growing list of insurance companies that already prov
coverage for Medicenter recuperation.

The Medicenter is a vital addition to our communi1
health care system. Get to know the Medicenter soon. Y
visit or inquiry is welcome anytime.

£-j\ Ylice Place to [jet Well

Medicenter of America / Columbus • Greenville, Mississippi

Students Get Chicago - Medical students in four states have
ive Membership full active, voting membership in medical as-
sociations. Colorado and Kansas have charter-
student societies, while Indiana and Pennsylvania have opened
ing membership to future physicians. In Mississippi, a committee
the Board of Trustees is working with UMC faculty and student
ders to set up voting membership for juniors and seniors who
1 have their own component, the University Medical Society.

Opposes Report Washington - AMA has filed objections to the
Payments to IRS IRS* proposal which would require insurance

carriers and Medicare to report "unassigned
nents" to care providers. About 13 million Americans have
tiple coverage, AMA said, and often collect more than charged
their physicians. Result of reports would be a distortion of
. income, making it appear that doctor had received entire
ant of benefit payments when, in fact, he had not.

tal Health Jackson - A $7 million investment will give

gram Progresses the state seven mental health centers serving

34 counties, according to the Interagency Colli-
sion on Mental Illness and Retardation. Centers are open and
rational at Oxford, Tupelo, and Gulfport with Clarksdale slated
Dpen soon. Another three centers are under construction at
snville, Jackson, and Meridian. Program was authorized by 1968
Lslature. Federal funds in project amount to $4 million.

Slams Teddy’s Washington - Lame duck liberal Sen. Ralph
Proposal Yarbrough (D. ,Tex. ) held bob tailed hearing on

Sen. Edward Kennedy's (D. ,Mass.) national health
irance bill, but Nixon administration bashed it as "inconceivable."
ts of program would be $77 billion per year, but this didn't stop
porters Mike DeBakey, Rashi Fein, Isadore Falk, and George Me any. ’
Lnistration blast was delivered by HEW Undersecretary Veneraan
sr Me any called AMA Medicredit "legislative quackery."

Dama Initiates Birmingham - The University of Alabama Medical
Lstant Training Center has its first class seeking baccalaureate

degrees as physicians' assistants. Students will
brained to take histories, do physical exams, handle casts and
srficial wounds, and perform diagnostic studies, relieving M.D.
aany time-consuming tasks. Program is patterned after that at
3 University for family practice. Pioneer program at University
Colorado emphasizes pediatrics.

MISSISSIPPI STATE MEDICAL ASSOCIATION

MSBH Studies
Waste Disposal

A State Board of Health survey shows 44
nunicipalities have no solid-waste collection ser-
vice and 29 have no designated site for disposal
)f such waste.

The survey is part of a three-year study of
vhat local communities need in order to control
he growing volume of bottles, cans and other
-efuse.

The survey is being made by personnel of the
Division of Sanitary Engineering, State Board of
Health, headed by Joe D. Brown, with V. T.
Hawkins of the division, designated by Brown to
direct the survey. Some 100 sanitarians at the
local level are participating in the survey, which
thus far has covered 262 municipalities and 132
unincorporated communities in 80 counties.

Figures compiled through August show 193
municipalities with some form of public collection
and 23 with private collection, with two having
both, leaving 44 municipalities with no collection
service for solid waste.

The figures also show 233 municipalities with
designated sites for the disposal of solid waste —
and 29 municipalities without such designated
sites.

Of the 132 unincorporated communities, five

1 5

have some form of public collection and 16 have
private collection, but the other 111 do not have
solid-waste collection services.

The survey shows 67 of the unincorporated
communities with designated sites for the disposal
of solid waste, but the other 65 do not have sites
designated for this purpose.

Hawkins estimates 1,925,558 tons of refuse
per year statewide, making an average of .89
tons per capita annually, using an estimated state
population of 2,161,680.

Brown and Hawkins discussed the data re-
cently with Elmer G. Cleveland, regional rep-
resentative, in Atlanta, of the Bureau of Solid
Waste Management, U. S. Public Health Service,

H. E.W.

Cleveland praised the State Board of Health
for being well ahead of schedule in its study,
scheduled to run from March 1, 1969, to March

I, 1972. In 1965, Congress passed a Solid Waste
Disposal Act providing grants to the states for
studies, and Gov. John Bell Williams designated
the State Board of Health to make the study.
The agency is matching, on a 50-50 basis, a
$31,000 U. S. Public Health Service grant.

“Solid waste programs, for example,” said
Cleveland, “fight all forms of pollution, because
solid waste emptied into water pollutes the water,
and solid waste burned in the open air pollutes
the air.”

—The lowest priced tetracycline— nystatin combination available—

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

November 1970, Vol. XI, No. 11

Amputations in Patients With
Peripheral Vascular Disease

RICHARD WARREN, M.D.
Cambridge, Massachusetts

Amputation in the lower extremity is perhaps
the oldest operation known to surgeons, but the
majority of patients undergoing it (who in civilian
life are largely older individuals with gangrene)
are not reaping the benefits of modern advances
in technique and rehabilitation. The reasons for
this are twofold.

First, although modern anesthesia, supportive
care, and antibiotic treatment have made thought-
ful and meticulous operations possible, many of
the tenets still being applied to the management
of these patients stem from a period years ago
when the amputations were done to save lives, the
patient's potential for rehabilitation to walking be-
ing a secondary consideration.

Secondly, although modern concepts of reha-
bilitation can be applied to the majority of these
patients, old time principles which make for de-
layed and discontinuous rehabilitation are still
practised in many centers. Eighty-five per cent of
the amputations for ischemia done in 166 Vet-
erans Administrations Hospitals were performed

Presented before the Section on Surgery, 102nd Annual
Session, May 12, 1970, at Biloxi.

From the Department of Surgery, Harvard Medical
School and the Surgical Departments of the Cam-
bridge Hospital and the Veterans Administration
Hospital, West Roxbury, Massachusetts.

by general surgeons with no competence or inter-
est in the techniques of postoperative ambula-
tion.1 This phenomenon is widespread through-
out the country and is one of the major draw-
backs of progress in the field.

The author discusses levels for amputation
in patients with peripheral vascular disease,
indications for surgery, preparation, tech-
niques and rehabilitation. Special emphasis
is given to various methods of rehabilitation
and the importance of assisting the patient to
walk again if possible. Some time-worn mis-
conceptions are pointed out and precautions
against them are listed.

The mortality among patients receiving ampu-
tations for arteriosclerosis is about 25 per cent at
the two year period and 50 per cent at five
years.2 The importance of treating the patient
with dispatch so that he may enjoy his later years
is not sufficiently realized.

Since the advent of arterial reconstruction tech-
niques almost 20 years ago, many legs have been
saved from amputation which otherwise would

NOVEMBER 1970

581

AMPUTATIONS / Warren

have been lost. The increasing age of the popula-
tion has, however, kept hospitals amply supplied
with individuals in whom arterial reconstruction
is not possible and therefore must receive ampu-
tation.

Emphasis on certain aspects of surgical tech-
nique not widely accepted or recognized is par-
ticularly important in patients with impaired cir-
culation. A partial list follows: (1) simple prep-
aration of the skin, (2) flaps cut so as to preserve
circulation, (3) gentle technique, single incisions,
(4) nerves divided without treatment, (5) pri-
mary closure with minimum number of sutures
and no drain, and (6) the part to be placed at
rest postoperatively.

The above principles put the least burden pos-
sible on the healing wound. A wound that is left
open must heal by secondary intention. It must
create infected granulations, thus requiring more
blood supply than the healing of a primarily
closed wound. Preparation of the skin is done
with soap and water or pHisoHex, no antiseptics
being applied. Attempts to wall off the lesion for
which the amputation is being done are usually
ineffective and are not recommended. This is un-
dertaken after the skin is prepared. The remain-
der of the items on the list are self-evident.

AMPUTATION LEVELS

The levels of election for amputations in is-
chemia are:

(1) transphalangeal, (2) transmetatarsal, (3)
Syme, (4) below knee, (5) through knee, or (6)
above knee.

Other levels in the foot, such as through the
tarsus, are unwise choices because of the thin is-
chemic skin that lies directly over the bone in
such amputations. Since the Syme and the
through-knee levels are used only rarely and only
by specially interested groups, only four sites of
election are commonly considered. Hip joint dis-
articulation, or even higher amputation has not
been listed, because it is rare indeed that a pa-
tient having the indications for operation at that
level presents a favorable prognosis for life.

Selection of one of the four areas is made on
the basis of the appearance of the skin at the site
of the proposed amputation. If it is not involved
actively in infection or in gangrene and is not
edematous, amputation should be undertaken at
the most distal level on the list regardless of the
state of the pulsations or of signs of collateral cir-
culation.

When the lowest pulse is at the femoral area
or higher and evidence for collateral circulation

582

is poor, the prognosis for healing at the point of
selection is, of course, less good than when lower
pulsations are felt, but that does not mean that
the level of election should be raised for this rea-
son. Likewise if there is very poor bleeding during
the operative procedure so that few, if any, ar-
teries need ligature, the prognosis for wound heal-
ing is not so good as in the vigorously bleeding
one, but the level should not be raised because of
this fact. Many wounds have healed in the ab-
sence of pulses in the area and of bleeding in the
wound requiring ligature.

It is clinical common sense, however, that if a
patient has no potential for walking and a very
ischemic limb, a more proximal amputation will
be selected than in a person with good potential
for rehabilitation.

INEVITABLE AMPUTATION

The chief factor that makes amputation in-
evitable is necrosis involving deep structures
(bone, tendon, joint, or joint capsule). Certain
patients with dry gangrene who are non-ambula-
tory and senile may be permitted to undergo auto-
amputation over a period of months. Otherwise,
surgical amputation is indicated.

There are four principles in the preparation for
amputation here:

(1) bed rest, (2) local drainage, (3) antibi-
otics, and (4) patience.

In many patients the level at which the amputa-
tion will be done, once it is decided upon, is clear.
In others the level will not be decided until the
period of preparation is over. If the lesion is dry
but infection seems to be spreading upward from
it, elevation of the corner of the eschar to see if
some drainage can be procured is helpful. This
should not be done to any major extent, and not
enough to cause bleeding.

If infection has been present, it often takes as
long as 10 days before a decision in favor of a
transmetatarsal amputation, for example, for a le-
sion of a toe, can be made.

The techniques of the various amputations are
detailed by Warren and Record.2 It is important
to follow them. Some of the more important have
been mentioned. One other should be empha-
sized. I refer to the incision for the below knee
amputation which consists of a long posterior and
an “absent” anterior flap. This arrangement
makes for the best circulation to the stump since
the dorsal flap is always the more ischemic.

REHABILITATION

1. Amputations in the foot. The following
principles apply:

(a) bed rest for 7-10 days, (b) first dressing

JOURNAL MSM A

at five days, (c) protect the heel and bony prom-
inences of both the amputated and the opposite
side, (d) overhead trapeze, (e) no cradle over
the foot, (f) first dependency on a trial basis,
(g) leave sutures in 14 days, and (h) full weight
bearing at between two and one-half and three
weeks.

The only exception to changing the dressing
first on the fifth day is if there is excessive pain
or fever before then, or if the wound hematoma
does not drain through and stain the dressing. In
the latter case it may mean that it is pocketed un-
der the flaps which then must be inspected. If the
hematoma has not drained then it should be evac-
uated. The trapeze is to allow the patient to move
around in bed without scuffing the opposite foot.
The banning of a cradle is to prevent the patient
inadvertently striking the wound against its rigid
frame.

Making the first dependency a trial means hav-
ing the patient sit on the edge of the bed with the
foot dependent, the dressing having been re-
moved. One then observes how long it takes be-
fore the wound area becomes suffused and cya-
notic. Periods of dependency to stay within that
limit are arranged during the next day or two.
The wound will rapidly become tolerant to longer
periods over the next four or five days.

2. Amputations above the foot. In patients
who are candidates for rehabilitation the immedi-
ate postoperative plaster technique is used as fol-
lows:

(a) The plaster is applied on the operating ta-
ble and changed weekly.

(b) During the first week the patient stands
but with no weight bearing.

(c) During the second week weight bearing
is started and becomes progressive (provided the
wound is normal to inspection).

(d) During the third week full weight bearing
is instituted. The sutures are removed during this
week.

(e) At the beginning of the fourth week the
“going home” prosthesis is provided and the pa-
tient is discharged before the end of it.

The advantages of this technique have now
been well established as follows:

( 1 ) Short hospital stay.

(2) Excellent patient morale.

(3) Return to prior (?home) environment fa-
cilitated.

(4) Continuity of medical responsibility in
that the doctor doing the surgery supervises the
rehabilitation.

(5) If the patient is a doubtful candidate for
eventual walking an early decision can be made

on the extent to which efforts and money should
be expended to accomplish it.

Clinics reporting results of the Immediate Post-
operative Plaster technique have nearly always
applied it to selected cases and primarily to be-
low-knee levels. Under these circumstances reha-
bilitation and healing success has been procured
in 80 to 90 per cent of patients.

It must be made clear that the technique is en-
tirely harmless, provided the plaster is properly
applied and weight bearing is not undertaken too
early. Furthermore, the advantages to be derived
in patients who are candidates for rehabilitation
are overpowering, as listed above.

CAMBRIDGE RESULTS

The results of the technique at the Cambridge
Hospital, for example, over a period of two years

were as follows:

Deaths

Uninterrupted rehabilitation success 9

Rehabilitation success after delay 1

Healing success, rehabilitation failure .... 2 1

Healing failure 7 3

19 4

In the above table, uninterrupted rehabilitation
success means that the patient was going home
walking with a prosthesis within four weeks. Re-
habilitation success after delay means that the pa-
tient healed successfully and walked but not with-
in the first four weeks. Healing success, rehabili-
tation failure means that the patient healed prop-
erly but did not turn out to be a candidate for re-
habilitation after trial with walking.

HEALING FAILURE

It is to be emphasized that this is a city hos-
pital in which patients are old and frail and that
our enthusiasm for the technique and exploring
its potentials made us apply it to nearly all
comers. The seven causes of healing failure
(which included three of the four deaths) are list-
ed as follows :

Hemorrhagic purpura (BK)

Thin skin over bone end (AK)

Postoperative seizure and injury to the stump . (BK)

Extension of sepsis from lower leg (AK)

Fell out of bed on cast (BK)

Advanced ischemia (BK)

Technical fault in operative technique (BK)

In the four survivors, the stumps were either
reamputated or the patient was sent out with an
open unhealed wound. In none of them could we
say that the technique was responsible for the
healing failure, an event that is only too familiar

NOVEMBER 1970

583

AMPUTATIONS / Warren

in this type of patient by the older techniques.

No discussion of amputations for ischemia
would be complete without mentioning diabetic
neuropathy and gangrene even though the pa-
tients at operation have good circulation and may
have even better than normal pulses in their feet.

The familiar picture is one in which severe in-
fection has invaded the foot of a diabetic with
neuropathy via a soft corn or a fungus infection.
Because of the lack of pain sensation it is neglect-
ed by the patient who finally appears with a
draining sinus in a swollen red foot and some ne-
crosis of one of the toes. The pulses are easily
palpable and the foot is surprisingly insensitive.

The principles of management are the reverse
from those with good circulation except that any
deep structure involved with the infection must
be removed, hence the term “drainage amputa-
tion.” Here primary closure cannot be done, in-
cisions must be wide and extend far more proxi-
mal than the infection so that dependent drainage
will be possible. The wounds are packed open.
The incisions for these amputations are demon-
strated in Warren and Record.2

The patient who was walking before he devel-
oped the lesion that caused the loss of his foot
should be able to walk again. Emphasis preop-
eratively, intraoperatively, and postoperatively
must be on future ambulation and this should be
understood by the patient from the beginning so
that optimism will prevail.

VARIED RESULTS

Different hospitals report varied results in
terms of rehabilitation, because their clienteles are
different. A city or a county hospital has a high
percentage of patients who come from nursing
homes and homes for the aged who have no po-
tential for walking and many associated diseases.
A private practice which caters to the well-to-do
will be at the other end of the spectrum, whereas
in between will lie the community hospital and
the veterans hospital groups.

In order to realize the potential of whatever
group one is dealing with, one must follow prin-

ciples similar to those outlined in this paper but
must also resolve to suppress certain misconcep- i
tions which have been passed down through gen-
erations of surgeons and are unfortunately wide-
spread. Here is a list of precautions against them:

1. Avoid precautionary preamputation sym-
pathectomy; it does not assist healing.

2. Eliminate the term “mid-thigh”; leave a
long lever arm in an AK amputation.

3. Do not succumb to the temptation of a
“provisional” BK incision with the idea of going
higher if bleeding is poor.

4. Eliminate “It is only an amputation — a
good case for the junior resident”; the patients
may be operated on by the junior residents, of
course, but only with the help of a Visit who is
educated in these matters.

5. Forget the old concept “the circulation is
so poor that the wound must be left open”; the
more granulation tissue, the more circulation is
required to heal it.

6. The presence or absence of diabetes does
not by itself affect the selection of level.

SUMMARY

The principles, detailed technique, preoperative
and postoperative care, indications, and selection
of level for patients with ischemic limbs undergo-
ing amputation are presented. In patients who
may be candidates for walking, the most distal
level of election where the skin is normal should
be selected, regardless of the state of the peripher-
al circulation.

An experience with the immediate postopera-
tive prosthetic fitting technique showed that of 19
patients 10 were uninterrupted rehabilitation suc-
cesses in a city hospital type of practice. The
technique is highly recommended.

A warning is sounded against certain time-
worn adages relating to amputations for ischemia
in the lower extremity. ***

REFERENCES

1. Veterans Administration Surgical Service Survey of

Lower Extremity Amputations for Ischemia. (VA

Form 10-2-313 (NR)) March 1966.

2. Warren, R. and Record, E. E. : Lower Extremity

Amputations for Arterial Insufficiency, Boston: Little,

Brown, 1967.

584 JOURNAL MSMA

Seminar on Care of the Newborn- V

Surgical Emergencies of the Newborn

RICHARD C. MILLER, M.D.

Jackson, Mississippi

Surgical emergencies of the newborn infant
are of multiple etiology. Generally such infants
will present with respiratory distress, abdominal
distention and vomiting, obstructive uropathy, tu-
mors of embryonic origin, or with abnormalities
of the central nervous system. In addition, there
are a number of infants with miscellaneous sur-
gical problems such as omphaloceles, fractures
and other manifestations of birth trauma, cu-
taneous defects, etc. This presentation will deal
with the principal surgical pathological conditions
leading to emergent respiratory and abdominal
distress. Anomalies of less urgent or elective na-
ture have been omitted.

Although those conditions leading to respirato-
ry distress are generally more urgent than those
causing abdominal problems, many of the ab-
dominal conditions nevertheless require prompt
attention if the infant is to survive. Little con-
solation may be gained from the adequate han-
dling of a respiratory emergency at two hours of
age only to have the child succumb to an un-
suspected abdominal abnormality a week later.
The management of any particular problem
therefore becomes one of priority. Prompt recog-
nition and treatment will usually lead to an im-
proved outcome.

Respiratory distress in the newborn infant may
be quite sudden in onset or may present from
the time of birth. Acute respiratory distress de-
mands aspiration of the pharynx and the estab-
lishment of an airway, with or without an endo-
tracheal tube. The nares and the esophagus
should be checked for patency and a chest film

From the Division of Pediatric Surgery, Departments
of Surgery and Pediatrics, University of Mississippi
School of Medicine, Jackson, Miss.

obtained. Several surgical diagnoses should be
considered.

Surgical emergencies of the newborn in-
fant are of multiple etiology and may in-
volve nearly all organs and areas of the
body. The author describes the principal
anomalies and abnormalities which may
lead to acute respiratory and abdominal dis-
tress. He gives special attention to atresia,
atelectasis, diaphragmatic hernias, obstruc-
tion, and gastrointestinal perforations.

As the newborn infant is an obligatory nasal
breather, obstruction of the nasal passages may
rapidly lead to asphyxiation. Choanal atresia is a
congenital malformation of the posterior nares in
which there is either a membranous or bony
block between the nasal cavity and the naso-
pharynx. The diagnosis may be rapidly estab-
lished by passing a small plastic catheter, usually
8 Fr. in size, through each side of the nose into
the pharynx. If an obstruction is encountered,
choanal atresia is likely and may be either unilat-
eral or bilateral. When one-sided, obstruction and
respiratory difficulty may occur if the single patent
side becomes plugged with mucus or if a catheter
is inserted. An oral airway is used as an imme-
diate but temporary measure. Surgical correc-
tion consists of relieving the obstruction and the
use of tubular splints for a period of several
weeks until the airway is well established and
epithelialized.

Although esophageal atresia represents an ab-

NOVEMBER 1970

585

The blowfish, a small spt
of fish, reacts to stress or
fright by puffing itself up
air. After about a dozen
noisy gulps the belly is ba
shaped and hard. When
replaced in the water th«
quickly expelled, and
the fish sinks to the botto

in the presence of spasm or hypermotility,
gas distension and discomfort, KINESED 5
provides more complete relief :

□ belladonna alkaloids — for the hyper-
active bowel □ simethicone — for ac-
companying distension and pain due to
gas □ phenobarbital — for associated
anxiety and tension

Composition: Each chewable, fruit-flavored, scored tab-
let contains: 16 mg. phenobarbital (warning: may be
habit-forming); 0.1 mg. hyoscyamine sulfate; 0.02 mg.
atropine sulfate; 0.007 mg. scopolamine hydrobromide;
40 mg. simethicone.

Contraindications: Hypersensitivity to barbiturates or

belladonna alkaloids, glaucoma, advanced renal or he-
patic disease.

Precautions: Administer with caution to patients with
incipient glaucoma, bladder neck obstruction or uri-
nary bladder atony. Prolonged use of barbiturates may
be habit-forming.

Side effects: Blurred vision, dry mouth, dysuria, and
other atropine-like side effects may occur at high doses,
but are only rarely noted at recommended dosages.
Dosage: Adults: One or two tablets three or four times
daily. Dosage can be adjusted depending on diagnosis
and severity of symptoms. Children 2 to 12 years: One
half or one tablet three or four times daily. Tablets may
be chewed or swallowed with liquids.

STUART PHARMACEUTICALS | Pasadena, California 91109 I Division of ATLAS CHEMICAL INDUSTRIES, INC.

(from the Greek kinetikos,
to move,

and the Latin sedatus,
to calm)

KINESED*

antispasmodic/sedative/antiflatulent

NEWBORN EMERGENCIES / Miller

normality of the alimentary canal, it clinically
presents as a problem in respiratory distress. The
most common (86 per cent) malformation is
that of a blind upper esophageal pouch with a
tracheoesophageal fistula between the lower
pouch and the trachea usually at the level of the
carina.1 Respiratory distress occurs when swal-
lowed saliva fills the blind upper pouch and over-
flows into the pharynx causing airway obstruc-
tion and aspiration.

Of equal or greater importance is the fact that
gastric juice may regurgitate via the lower seg-
ment fistula directly into the lungs. Although sud-
den regurgitation of mucus from the upper pouch
may cause acute cyanotic episodes, it is the re-
peated soiling of the lungs with gastric acidic
fluid which may cause the most amount of diffi-
culty in terms of pneumonitis. This is illustrated
by the example that infants with pure esophageal
atresia without fistula may have less difficulty
with pneumonitis than those patients in whom a
distal fistula is present.

ESOPHAGEAL ATRESIA

Esophageal atresia should be suspected in any
infant with excessive salivation. It should further
be recognized that the mothers of infants with
high intestinal obstruction, either at the level of
the esophagus or duodenum, may have hydram-
nios because the fetus cannot swallow or absorb
normal amounts of amniotic fluid. Thus, it be-
comes axiomatic that any child born of a mother
with hydramnios of unexplained origin is a candi-
date for investigation of esophageal patency. This
may be easily accomplished by the passage of a
nasogastric tube. However, care must be taken to
avoid the situation where a small flexible plastic
catheter may turn or curl in a blind esophageal
pouch giving the examiner a false sense of se-
curity as to the length of the esophagus.

When esophageal atresia is suspected, it is far
safer to pass a No. 12 or 14 Fr. catheter through
the mouth. A tube this size and stiffness will not
curl in the pouch and will meet an obstruction
at about 12 cm from the upper alveolar ridge if
esophageal atresia is present. Although the dis-
tance from the alveolar ridge to the end of the
pouch will vary somewhat from infant to infant
depending on size, birth weight, and the level of
atresia, this measurement is surprisingly constant
with a variance of only one or two cm either way.

A blind upper esophageal pouch filled with air
is often visible on A-P and lateral chest x-rays,
while the presence or absence of gas in the stom-

ach on the same films will give an indication of
the presence or absence of a distal pouch tracheo-
esophageal fistula. In fact, infants with tracheo-
esophageal fistulae often have increased amounts
of gas in the abdominal viscera as air is forced
through the fistula during expiration, particularly
when the baby cries.

RADIOLOGIC DIAGNOSIS

The diagnosis of esophageal atresia may be
confirmed radiologically after a controlled amount
of water soluble x-ray contrast material has been
placed in the blind upper pouch. During this pro-
cedure, care must be taken to deliver a precise
amount of dye (not over 1 cc) into the pouch
to prevent overflow aspiration. This is accom-
plished by first aspirating the upper pouch of all
mucus and then inserting a contrast filled catheter
into the pouch with syringe attached. One-half to
one cc of 30 per cent contrast material is then in-
stilled into the pouch, a lateral upright film is
taken, the dye aspirated, and the catheter re-
moved. While the use of contrast material may
not be necessary to establish a diagnosis which
has already been clinically confirmed by the
use of a catheter, it will help to rule out those
rare cases where there is also an upper pouch
tracheoesophageal fistula.

Management of the child with esophageal
atresia and tracheoesophageal fistula should in-
clude an early gastrostomy under local anesthesia.
The gastrostomy tube is placed to suction to
minimize the possibility of regurgitation of gastric
juice into the airway. Immediate and continuous
attention must also be paid to keep the upper air-
way free of mucus and to treat any pneumonitis
or atelectasis which may already be present.

SUCTION MANAGEMENT

Management of the upper pouch consists of
oropharyngeal suctioning through the mouth at
15 minute intervals. Aspiration in this fashion in-
sures that the blind upper esophageal pouch will
be kept empty of saliva. The use of an indwelling
catheter in the upper pouch placed to constant
suction may be helpful but may lead to com-
placency and should not replace constant obser-
vation and intermittent aspiration by the nursing
staff.

The definitive therapy of esophageal atresia is
that of a thoracotomy with division of the fistula
and establishment of esophageal continuity by
anastomosis. This procedure should be attempted
only when conditions as related to the respiratory
status are optimal.

Post-operatively, the gastrostomy is used for

588

JOURNAL MSMA

feeding until esophageal continuity is assured by
an esophagogram on the fifth or sixth day. There-
after, the tube may be sealed but left in place
until a repeated barium swallow at four to six
weeks shows no evidence of esophageal stricture.
If stenosis at the suture line has developed, a
string may be passed and the gastrostomy used
for retrograde dilatations.

Much more infrequently (3-4 per cent), in-
fants may present with an H-type tracheoesopha-
geal fistula without atresia. These lesions are often
difficult to diagnose as the fistula may be of small
caliber and only infrequently passes material from
the esophagus into the trachea. Any child with
repeated coughing or respiratory distress associat-
ed with feedings should be suspect. The diagnosis
is best established with cineffuorographic studies.
Frame by frame analysis of the movie film is
essential, and repeated studies are often neces-
sary. Unlike the common type of esophageal
atresia, where the tracheoesophageal fistula is usu-
ally at or near the carina, H-type fistulae may oc-
cur anywhere along the posterior wall of the
trachea and are often at the cervical level.

PNEUMOTHORAX

Pneumothorax is not an infrequent complica-
tion of infants with respiratory distress, with or
without vigorous attempts at resuscitation, and
may occur in otherwise asymptomatic infants. It
may be secondary to the “air block” phenome-
non. In this situation, blockage of an air passage
may produce markedly altered pressure relation-
ships within the chest with subsequent rupture of
alveoli and dissection of air subpleurally along the
bronchi. Air may then dissect either into the me-
diastinum producing pneumomediastinum or may
break into the pleural space producing pneumo-
thorax. As air in the pleural space increases, it
in itself becomes a source of increasing respira-
tory distress.

A small amount of unilateral pneumothorax in
a child without respiratory distress may on oc-
casion be observed and will subside spontaneous-
ly. In other instances, it may be wise to aspirate
the air or to place a thoracotomy catheter to
waterseal drainage and suction particularly if
there is an increasing amount of air with me-
diastinal shift, herniation of the pleura to the
opposite hemithorax, or bilateral pneumothorax.
When there is doubt regarding the amount or
significance of pneumothorax, or as to the avail-
ability of adequate nursing personnel, it is by far
wiser to place a thoracotomy tube.

Occasionally, total or partial collapse of an en-
tire lung may result from the aspiration of amni-

otic fluid or from other secretions. Such an in-
fant presents with respiratory distress, and opaci-
fication of the lung by x-ray. Vigorous efforts are
indicated to inflate the lung before consolidation
and infection ensue. This may be simply done by
passing a small smooth-tipped catheter into the
trachea under direct laryngoscopy. Aspiration of
the secretions may immediately correct the prob-
lem.

ALTERNATE METHOD

An alternate method is to insert an endotracheal
tube through which the infant may alternately
be suctioned and supplied with oxygen. This lat-
ter method enables the physician to aspirate re-
peatedly without additional trauma to the larynx.
An atmosphere of high humidity and mist, along
with postural drainage and pulmonary physio-
therapy, is essential if recurrence of the collapse
is to be avoided. All aspirated secretions should
be preserved for culture and antibiotic sensitiv-
ities.

Diaphragmatic hernias causing acute symptom-
atology in infancy are largely of the postero-
lateral, foramen of Bochdalek, type. This foramen
represents a persistence of the embryonic pleuro-
peritoneal canal. The great majority of these her-
nias occur on the left side where there is no but-
tressing by the liver and where persistence of the
foramen allows the abdominal contents to reside
in the left pleural cavity. Usually these hernias
have no true sac. Depending on the amount of
abdominal viscera in the chest and the amount of
air swallowed, respiratory distress may be present
soon after birth or may develop during the first
few days or even weeks of life.

DIAGNOSTIC PROBLEMS

An occasional child or adult with limited her-
niation may be entirely asymptomatic. The diag-
nosis of diaphragmatic hernia cannot be made ac-
curately without a chest film since breath sounds
from the right side of the chest are easily trans-
mitted and heard on the left side. Similarly,
bowel sounds may be transmitted from the ab-
domen in a normal infant. Dullness and de-
creased breath sounds in the left side of the chest,
accompanied by a mediastinal and cardiac shift
to the right side, are presumptive evidence for
the diagnosis of diaphragmatic hernia. An emer-
gency chest film is then indicated.

Once the diagnosis of diaphragmatic hernia
has been established, operative intervention
should follow without delay. While awaiting sur-
gery, a nasogastric tube should be inserted and
placed on suction hopefully to prevent further

NOVEMBER 1970

589

NEWBORN EMERGENCIES / Miller

distention of the stomach and viscera residing
within the chest. If respiratory distress is marked,
an endotracheal tube with positive pressure as-
sistance of respiration is indicated. Positive pres-
sure with a face mask should be avoided as air
may be forced down the esophagus, further com-
promising respiratory status.

The operative procedure should be accom-
plished through an upper abdominal subcostal or
transverse incision which gives immediate access
to the diaphragm. A thoracic incision should be
avoided since the surgical problem is usually not
one of closure of the hernia defect but rather one
of accommodating the viscera in the unused ab-
dominal cavity. It is far more difficult to attempt
to stuff the intestine into the abdomen from above
the diaphragm than it is to deliver the intestine on
to the operating field from below the diaphragm, to
complete the hernia repair, and then to replace
the intestine into the abdomen closing only skin
if it is found that a fascial closure will compromise
respiration.

In most instances, however, it is possible,
after manual stretching of the abdominal wall,
to reduce the entire bowel into the peritoneal
cavity and to accomplish muscle, fascial, and
skin closures. In addition, the intestinal tract
should be inspected for other congenital anom-
alies, particularly those of abdominal adhesions
and bands associated with malrotation which is
almost invariably present.

CLOSING THE DEFECT

Usually the diaphragmatic defect is closed
without an indwelling thoracotomy catheter. In-
stead, the mediastinum is shifted to the midline
by negative pressure produced with a rubber
bulb syringe and rubber catheter which is removed
from the chest as the last diaphragmatic suture is
tightened. The anesthesiologist may assist during
this portion of the procedure by advising when
the cardiac impulse has shifted from the right
side to the midline or slightly to the left. No at-
tempt should be made to forcibly inflate the un-
expanded lung since this often results in a rup-
ture of pulmonary tissue and a continued air
leak. Usually, left alone, the uninflated lung will
expand slowly over the course of the first few
post-operative days as the pneumothorax is ab-
sorbed. On occasion, true agenesis of the lung may
be encountered.

Upper airway obstruction may result from a
number of deformities about the mouth, palate,
neck and pharynx as well as from congenital
cervical tumors including goiter. These deformities

often predispose to incoordination of the swallow-
ing mechanism with resultant aspiration and cy-
anotic episodes, especially at the time of feeding.
Treatment in many infants may consist of naso-
gastric tube feedings or of the use of a gastros-
tomy.

Of particular interest are those infants with
micrognathia and glossoptosis (Pierre-Robin Syn-
drome). Failure to control the tongue in such pa-
tients may result in sudden asphyxiation. These
infants require intensive nursing care. A silk su-
ture may be placed through the tip of the tongue
as a temporary measure to keep the tongue for-
ward or to be used for traction during a cyanotic
episode.

LOBAR EMPHYSEMA

Lobar emphysema may cause acute respiratory
distress in infancy and is manifested by a me-
diastinal shift and a hyperlucent area in the lung
fields on chest x-ray. The x-ray may appear so
hyperlucent as to be confused with pneumothorax,
but scattered lung markings are usually visible
and serve to establish the correct diagnosis. The
emphysema usually involves a single upper lobe.
Treatment consists of lobectomy.

Although ascites is a rare entity in the newborn
infant, it does on occasion present a severe prob-
lem with abdominal distention and secondary res-
piratory distress. This is especially true in those
infants born with ascites in whom the diaphragms
are extremely high and in whom the neonatal
respiratory state is severely compromised from
the outset. Although of multiple causes, neonatal
ascites should be treated by paracentesis at the
first sign of respiratory distress. It is by far better
to tap an abdomen not knowing what is there
than to risk further respiratory deterioration.
When respiratory distress is not a problem, ab-
dominal x-rays and intravenous urograms may be
obtained prior to paracentesis.

ABDOMINAL EMERGENCIES

The classical presentation of a newborn in-
fant with an intestinal abnormality is that of
bile-stained vomiting, distention, and failure to
pass normal meconium. It should be noted, how-
ever, that a distended abdomen generally implies
the patency of a sufficient number of intestinal
loops which may enlarge as air is swallowed. It is
therefore apparent that children with high intes-
tinal obstruction, either of the duodenum or proxi-
mal jejunum, may have maximally distended in-
testine without overall distention of the abdomen.
If there is any suspicion of an intraabdominal
problem, feedings should be discontinued at once
and x-rays of the abdomen obtained.

It is our custom to request A-P, supine and up-

590

JOURNAL MSM A

right, and lateral films of the abdomen. The later-
al film is often helpful in detecting the presence
of colonic gas, especially in the area of the rec-
tum. These plain abdominal films, which use air
for contrast, will provide most surgical diagnoses.
However, there will always be some infants
where the diagnosis will be less obvious and
where the differential lies between that of a para-
lytic ileus, perhaps associated with sepsis, and
that of a low intestinal obstruction such as Hirsch-
sprung’s disease. In these infants, it may be neces-
sary to proceed with a barium enema. The bari-
um enema is particularly helpful in the diagnosis
of malrotation, Hirschsprung’s disease, and the
meconium plug syndrome. In the latter instance,
it may also be curative since the enema itself will
wash out the plug. It should also be noted that
the diagnosis of Hirschsprung’s disease by barium
enema in the newborn infant may be difficult as
the change in caliber from a distally contracted
to a proximally dilated bowel may not be ap-
parent at this age.

When a surgical condition has been diagnosed,
the infant should be placed on nasogastric suc-
tion, and hydrated with intravenous fluids. How-
ever, most newborn infants, unless they have
been neglected for some time and have had
considerable vomiting, will be in normal electro-
lyte balance. Intraoperatively, temperature regu-
lation with a heating mattress and a continuously
recording rectal thermometer should be provided.
In the small premature infant, many abdominal
operations may be completed under local anes-
thesia. Regardless of whether a local or general
anesthetic is used, the anesthesia team should be
present to continuously monitor the patient.

ATRESIA

Atresia is the most common cause for intestinal
obstruction in the newborn (imperforate anus ex-
cepted). Most commonly occurring in the ileum or
duodenum, atresias are less often encountered in
the jejunum and rarely in the colon. The diagnosis
is readily suspected from the plain abdominal
x-rays and in the case of duodenal obstruction,
the infant presents with a classical double-bubble
appearance. The two bubbles represent stomach
and dilated duodenum. In almost all cases of
duodenal obstruction, the level of obstruction is
distal to the common bile duct and the infant
therefore vomits bile stained fluid.

Although it is impossible on the basis of x-ray
to accurately predict the cause of duodenal ob-
struction, it makes little difference from the sur-
gical point of view. Since patients with annular
pancreas also have an underlying duodenal atresia
or stenosis, the operation for congenital duodenal

obstruction consists of the shortest possible by-
pass. In most infants, this may be accomplished
with a duodenoduodenostomy, although occasion-
ally a duodenojejunostomy may be necessary. A
gastrojejunostomy should be avoided.

When atresia occurs more distally in the bowel,
the level of obstruction may be surmised from
the number of small intestinal loops visible on the
abdominal films. Usually the most distal loop just
proximal to the point of atresia will be markedly
dilated. At operation, atresia of the distal bowel
should be handled by adequate resection of the
blind, dilated, atonic, proximal loop and by an
end-to-end anastomosis to the distal bowel. The
surgeon must be certain that the distal bowel has
internal continuity for its entire length. Patency is
insured by injection of saline through a small
needle into the lumen of the distal intestine and
by watching the saline proceed all the way to the
sigmoid colon.

ANASTOMOSIS

Although it may be technically more difficult,
an end-to-end anastomosis is preferred and should
be accomplished with a single layer of inter-
rupted 5-0 atraumatic silk sutures. Care should be
taken not to turn in a large cuff since this easily
obstructs the anastomosis. Internal splints or cath-
eters are not used, and every effort is made to
be sure that the anastomosis is not angled or
doubled upon itself as the bowel is replaced into
the abdomen. A side-to-side by-pass anastomosis
should be avoided because it may leave a blind
intestinal loop.

Malrotation of the intestine, in itself a benign
anomaly, is associated with other abnormalities
which may produce acute symptomatology in
newborn infants. Of particular importance are ex-
trinsic duodenal bands, and lack of mid-gut fixa-
tion. While duodenal bands may produce a par-
tial or complete obstruction of the bowel at that
level, an unfixed mid-gut may undergo volvulus
as it hangs suspended on the axis of the superior
mesenteric artery.

INTESTINAL INFARCTION

Unless corrected, infarction of the intestine
from the ligament of Treitz to the transverse
colon may rapidly ensue. If this catastrophy is to
be avoided, surgical intervention should follow
quickly upon the diagnosis of acute intestinal ob-
struction especially where there is distention of
the entire small bowel. Although a barium enema
will usually suggest the correct diagnosis by vir-
tue of confirming the presence of a malrotation,
it is not a mandatory study and should never de-
lay operation.

At laparotomy, the mid-gut volvulus, which is

NOVEMBER 1970

591

NEWBORN EMERGENCIES / Miller

usually in a clockwise direction, should be re-
duced, following which the surgeon must make a
systematic search to rule out other congenital
anomalies and to look for abnormal duodenal
bands and other adhesions. All abnormal adhe-
sions and attachments should be lysed. Mean-
while the bowel involved in the volvulus may be
observed for areas of questionable viability. Fi-
nally, it is necessary to check the internal con-
tinuity of the duodenum because of the known as-
sociation of intrinsic stenoses and webs with ex-
trinsic adhesions and bands. This is most con-
veniently accomplished by passing a duodenal
catheter through a small gastrotomy.

Approximately 10 per cent of infants born with
cystic fibrosis will have a meconium problem in
the neonatal period. Within this group of patients,
there will be a wide spectrum of disease from
those infants presenting with mild colonic ob-
struction due to sticky meconium and to those in-
fants with the full-blown picture of inspissated
meconium in the ileum or jejunum, with or with-
out secondary volvulus and atresia.

MECONIUM ILEUS

A number of the patients will have perfora-
tions and meconium peritonitis as may be diag-
nosed radiologically by intraabdominal calcifica-
tion. The infants with meconium ileus presents
with a distended abdomen, with or without pal-
pable meconium-filled loops, and an x-ray pattern
suggestive of distal small bowel obstruction. Me-
conium ileus has the distinction of being the only
form of intestinal obstruction where fluid levels
are not usually visible on the upright abdominal
film, simply because the meconium is too vicid to
layer out.

Recent investigations have shown that a num-
ber of children with meconium ileus may be treat-
ed with hypertonic enemas using x-ray contrast
materials. The technique involves the reflux of
contrast material through the colon and into the
small bowel under fluoroscopic control. The con-
trast material should enter the dilated loops above
the area of obstruction where its hypertonic na-
ture produces an influx of fluid from the wall of
the gut with subsequent lysis of the obstructing
meconium and passage per rectum. This tech-
nique was first described by Noblett.2 The enema
may be repeated in 24 to 48 hours if there is
still obstruction.

Elowever, it should be stressed that all cases
of meconium ileus may not lend itself to this
form of therapy, particularly when there is evi-
dence of meconium peritonitis signifying perfora-

tion or when associated atresias are suspected. In
the latter situations, the operative approach with
decompression of the bowel, evacuation of the
meconium, and with one of several surgical
anastomoses is indicated.

It must be stressed that the post-operative
prognosis of the child with meconium ileus lies
with vigorous and continuous therapy of the pul-
monary complications which will soon ensue. It
is essential that these children receive the maximal
effort in pulmonary care from the immediate new-
born period.

PERFORATIONS

Spontaneous perforations of the gastrointestinal
tract occur in early infancy, and present a true
surgical emergency. The overall survival rate in
these infants has generally not been better than
50 per cent. Perforations have been reported in
anatomical locations from the stomach to the
anus and in the majority of instances, when not
associated with other anomalies, are seemingly
without obvious cause.

Of particular interest are a group of perfora-
tions occurring in premature infants along the
greater curvature of the stomach. Because these
perforations may involve a long linear rent of
almost the entire stomach, massive pneumoperito-
neum and abdominal distention often results.
However, other perforations in the duodenum
and small bowel may also give rise to a con-
siderable amount of intraperitoneal air. Fluid and
electrolyte imbalance, peritonitis, and septicemia
rapidly ensue, and unless treatment is prompt and
vigorous, the infant may not survive.

ABDOMINAL X-RAY

Any infant with undiagnosed distention of the
abdomen requires an abdominal x-ray. Unlike the
adult patient, signs and symptoms of perforation
may be lacking in the neonate; and the infant
with a perforation characteristically may continue
to feed until the problems of peritonitis and ab-
dominal distention become grossly evident. As
in the infant with neonatal ascites, massive dis-
tention of the abdomen which embarrasses res-
piratory efforts, should be treated with immediate
paracentesis. Treatment of the perforation is that
of laparotomy and surgical repair after intra-
venous antibiotics, fluids, and nasogastric suction
have been instituted.

Gastrointestinal hemorrhage in the newborn in-
fant is not a common problem. Although hemor-
rhage may occur secondarily to a number of gas-
trointestinal tract lesions, it is well to first con-
sider that the infant may have a bleeding dis-
order and appropriate hematological consultation

592

JOURNAL MSM A

should be obtained. Surgical intervention should
be considered only when it is clear that the pa-
tient does not have a bleeding disorder and when
conservative management has not led to cessation
of bleeding.

Congenital aganglionosis of the colon, common-
ly known as Hirschsprung’s disease, may cause
acute obstructive symptomatology in the new-
born infant. However, as most children with
Hirschsprung’s disease become manifested in
later infancy or in the preschool years, it is easy
to overlook this problem in the neonate particu-
larly when the diagnosis is difficult and not at all
obvious. Abdominal x-rays may mimic those of a
paralytic ileus, and the barium enema may not
show the characteristic disparity in size, which is
so commonly seen in the older child between the
dilated, proximal, ganglionic bowel and the con-
tracted, distal, aganglionic segment. However,
Hirschsprung’s disease must enter into the differ-
ential diagnosis of any acute neonatal intestinal
obstruction, particularly when the obstruction ap-
pears to be in the colon. Hirschsprung’s disease in
infancy may be further complicated by severe
enterocolitis in the proximal obstructed intestine.
This complication is a particularly lethal problem
in the young infant and must be treated by an
emergency decompressing colostomy above the
aganglionic area.

It is therefore apparent that any infant, in
whom the diagnosis of Hirschsprung’s disease is
suspected, should receive prompt attention. At
the time of colostomy, it is essential to obtain a
frozen section of the bowel at the colostomy site
to be sure that the decompression has been ac-
complished in a normally ganglionic area. The
colostomy, if possible, should be placed just prox-
imal to the area of aganglionosis. When time and
the patient’s condition permit, definitive diagnosis
may be made by colonic biopsy taken from the
rectum above the level of the internal sphincter.

Although there is some recurrent interest in
primary surgical pull-through procedures in the
neonatal period using some of the newer surgical
techniques, most surgeons would still prefer a
temporary diverting colostomy with a pull-
through procedure at a later date.

IMPERFORATE ANUS

Although the diagnosis of ‘‘imperforate anus”
may be easily established by physical examina-
tion, the exact underlying embryological deformi-
ty is not always as apparent. Intelligent manage-
ment of the infant depends upon an accurate em-
bryological and anatomical knowledge regarding
the level of deformity, the relationship of the rec-
tal pouch to the levator ani sling mechanism

and the presence or absence of any fistulae,
either internal or external. It is now appreciated
that the term “imperforate anus” encompasses a
multiplicity of anomalies of the rectum, anus and
perineum. At a recent international congress of
pediatric surgeons, 39 different deformities were
documented.

Examination of the newborn with imperforate
anus should include a close inspection of the
perineum, particularly in the male, for a minute
fistulous tract. These fistulae are often not ap-
parent until several hours after birth when me-
conium has been forced into the tract making it
visible. In the female, inspection of the perineum
should include the area of the vestibule and lower
posterior vaginal wall as fistulae are often present
in these areas.

If a fistula is not present, the next step is that of
the upside down x-ray as was originally de-
scribed by Wangensteen and Rice.3 On these films,
the relationship of the blind rectal pouch to the
pubococcygeal line should be noted.4 If the
pouch is well distended and ends above the line,
one can assume that there is a “high,” supraleva-
tor deformity and that the bowel has not passed
through the levator sling. A rectal fistula in these
patients enters either into the posterior urethra
or bladder in the male, or into the high vagina or
cloaca in the female. Any child with a supra-
levator deformity should be treated with colostomy
in the neonatal period pending a definitive pull-
through procedure at about one year of age. In
situations where the deformity is infralevator or
where there is a fistula to the perineum, a local
perineal surgical procedure will usually provide
egress for meconium without the need for a
colostomy.

Infants with imperforate anus have an in-
creased incidence of atresias elsewhere in the
alimentary tract, especially in the esophagus, as
well as a greater number of urinary tract anom-
alies. A nasogastric tube should always be in-
serted to check esophageal patency, and a sub-
sequent intravenous urogram should become a
routine part of the patient’s diagnostic work-up.

★★★

2500 N. State Street (39216)

REFERENCES

1. Miller, R. C., and Moynihan, P. C.: Esophageal
atresia. South. Med. J. 63:939, 1970.

2. Noblett, H. R. : The treatment of uncomplicated
meconium ileus by Gastrografin enema. J. Pediat.
Surg. 4:190, 1969.

3. Wangensteen, O. H., and Rice, C. O.: Imperforate
anus: a method for determining the surgical approach,
Ann. Surg. 92:77,1930.

4. Stephens, F. D.: Congenital Malformations of the
Rectum, Anus and G enito-U rinary Tracts. E. and S.
Livingstone, Ltd., London, 1963.

NOVEMBER 1970

593

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Illustrations must be numbered and cited
in the text. Legends, not exceeding 40
words and preferably shorter, must accom-
pany each illustration, typed double spaced
on separate sheets. The following informa-
tion should appear on a gummed label af-
fixed to the back of each illustration: Figure
number, manuscript title, author’s name,
and arrow indicating top of the illustration.

In photographs in which there is any
possibility of personal identification, an ac-
ceptable legal release must accompany the
material.

A thesis summary of 75 to 100 words
must accompany each manuscript separately
from the text.

Reprints may be obtained at cost plus
shipping charges from the association and
should be ordered prior to publication. The
Journal reserves the right to decline any
manuscript. Authors should avoid placing
subheads in the text, and the Editors re-
serve the prerogative of writing and insert-
ing subheads according to Journal style.
— The Editors.

594

JOURNAL MSMA

Youth and Drugs

CARL E. GUERNSEY, LL.B.

Jackson, Mississippi

I can say quite honestly that most of the infor-
mation I have acquired regarding drug abuse has
come from conferences with a wide range of au-
thorities. The very fact that there is no central
fountain of knowledge on this tremendous
problem points up our inexcusable tardiness in
dealing with one of the greatest crises of our
time. We have profited greatly from our contact
with Joe Moynihan, narcotic authority for the
State Board of Health; we have worked closely
with the Jackson office of the Bureau of Narcotics
and Dangerous Drugs; we have sought the knowl-
edge of the investigators for the State Board of
Pharmacy; we have been given aid by the admin-
istrative heads of Whitfield and East Mississippi
Hospitals. Much help has been given us by the
Bureau of Narcotics and the crime lab for the
Jackson Police Department and by the Highway
Patrol Narcotic Division. Why is there no central
source of information and why especially is there
not a dynamic planning and action drug control
authority in Mississippi?

There have been other sources of information
for the remarks I make here — face to face con-
frontation with pitiable children of talent who
cried for help to wrest them from the grip of nar-
cotic addiction or dependency; and the obituaries
of children I have known whose deaths have been
caused or contributed to by inhalants or narcotics.
Any person who has analyzed the trend of pyra-
miding drug usage knows that we cannot afford
the spiraling economic and social cost. Any per-
son who has seen the stark tragedy in the eyes of
an addicted child must have a very personal rea-
son for a commitment to action.

Presented before the Section on Preventive Medicine,
102nd Annual Session. May 13. 1970, at Biloxi.
Presiding Judge of the Hinds County Youth Court. Jack-
son.

Drug addiction was for many years almost ex-
clusively an adult problem. In 1958, only 3.8 per
cent of arrested drug violaters were under 25. In
1968, 3 per cent of arrested drug violators were

Drug use and abuse is a rising problem
among American youth. The author, Presid-
ing Judge, Hinds County Youth Court,
points out the lack of drug authorities, in-
formation services, and avenues of treatment
for youthful users. He discusses initial steps
that could be taken in forming a compre-
hensive plan to deal effectively with this ma-
jor social crisis.

under 15; 26.6 per cent were under 18; and 76.6
per cent were under 25. From July 1968 to July
1969, more than 6,200 children under age 15
were arrested for drug law violation in this coun-
try. Despite these facts, very few states have any
kind of treatment program for the teen-aged ad-
dict and any one under 18 is excluded by admin-
istrative ruling from the narcotic hospitals at Lex-
ington and Fort Worth administered by the Na-
tional Institute for Mental Health, a division of
the Department of Health, Education and Wel-
fare.

I, here and now, charge the Department of
Health, Education and Welfare with discrimina-
tion against youth in the operation of narcotic
hospitals and with depriving the young of equal
protection of the law. I submit that it is time they
realized that addicted children are as much en-
titled to treatment as addicted adults. I do not
pretend to know all the factors contributing to
drug addiction and I doubt if anyone present

NOVEMBER 1970

595

YOUTH AND DRUGS / Guernsey

would claim such knowledge which would have to
approach omniscience. Emotional or mental dis-
orders or chemical unbalance, physical weakness
or temporary depression can couple with drug
experimentation or medical treatment to create
addiction. Perhaps the greatest drug chaos of our
time is the use and abuse of amphetamines by
overweight Americans. Their story is told time
after time in the admission records of mental hos-
pitals. So diverse and complex are the causes of
addiction that we err badly in our blanket con-
demnation of the drug addict or dependent.

In order to fully evaluate the drug problem
which we encounter we must consider specific
facts peculiar to this problem. Of all crime or
health problems confronting our nation, drug ad-
diction and dependency are the hardest to mea-
sure in scope. Both a felonious vendor and an ad-
dicted buyer will go to any extreme to conceal the
fact of a crime committed or of a physical addic-
tion indulged. It is not so with either bank rob-
bery or cancer. We cannot presently solve the
drug problem, and can’t even measure it, and
many persons in positions of prominence will not
even admit that it exists. If we could determine
the quantity of drugs used in violation of our
laws, and we can’t, we still would not know the
number of users or the measure of their addiction
or dependency.

INADEQUATE ENFORCEMENT

Federal, state and local law enforcement au-
thorities are not yet geared to a drug traffic more
than 10 times as great as that in the beginning of
the 1960’s. We have in Mississippi today fewer
than 10 full time state narcotic officers, and only
seven police departments in our state have nar-
cotic units. Six of these have been established
within the past year. This force is ill-equipped to
deal with more than 1,000 drug users in our state,
many of whom are actively recruiting new users.

Our criminal laws offer little or no alternative
to long term sentences. By such sentences we can
vent our public wrath on a perplexing problem
without expending the energy required to seek its
proper solution. We have not yet accepted drug
addiction as a medical problem or treatment as
an alternative to prison.

The comparative handful convicted of drug
usage receive little or no treatment nor have our
hospitals or prisons ever effectively cut off their
source of supply, even during periods of confine-
ment. In some places hospital attendants and

prison guards are our country’s worst pushers,
and they are protected by a monopoly any Wall
Street broker would envy.

These are only a few of the many indications
that our nation is still figuratively sitting on its
hands, seemingly unwilling to commit itself to an
intelligent and effective drug control program. If
and when the State of Mississippi fixes attention
and resolution on the drug problem and creates
a drug authority, equipped with manpower, legal
power and know how to cut this serious problem
down to manageable size, a positive plan of action
should be adopted. These nine steps should be at
the heart of our solution as I see it:

( 1 ) Drug education today is as faulty and in-
adequate as the sex education made available to
my generation. We try to solve a very real prob-
lem with unreal answers, half truths and plati-
tudes, and failing to impress, we threaten instant
insanity. Just as our parents substituted, in many
cases, scare tactics for facts about sex, so are we
giving our children a “birds and bees” story about
drugs. Drug education must be introduced inten-
sively into the public school curriculum during
late elementary years and continued through high
school and based upon honest research and hard
facts. Surveys indicate that only half a dozen
school systems in the country have effective drug
education programs.

(2) An intelligent drug control program must
commence with a medicine cabinet inventory.
Amphetamines, barbiturates, benzedrine, nail pol-
ish, glue, hair spray, gasoline and lighter fluid are
all capable of providing children with the first
step of a long trip, right in their own homes. No
child will take seriously the drug advice of par-
ents whose “uppers” and “downers” are a regular
part of their lives.

(3) By legal requirement and cooperation of
pharmaceutical and medical personnel, modern
computer techniques can uncover the prescrip-
tion shopper and the rare pharmacist or the rare
physician who makes narcotics or drugs too easily
available. Let me emphasize here that I fully ap-
preciate the need for safeguards against witch-
hunting and second-guessing regarding profes-
sional judgment on medication.

Names of druggists, physicians, patients and
dosage of drugs could be easily keyed to a com-
puter card which could be incorporated into a
comprehensive record system. By proper inquiry
of a mechanical brain we could have an instant
accounting of the drugs a pharmacist buys and
dispenses, those a doctor prescribes and those a
patient receives. To avoid use of false names, pa-
tient’s social security numbers could be used.

(4) In every area of crime, effective law en-

596

JOURNAL MSM A

forcement is a part, but only a part of the solu-
tion. All the policemen in the world could not
solve our drug problem unless and until the courts
to which the cases are referred have treatment al-
ternatives available. Nevertheless, drug traffic will
never be broken without adequate numbers of
well-trained narcotic officers. In addition to the
shortage of state narcotic officers, one example
of our deficiency in this area is the fact that the
Federal Bureau of Narcotics and Dangerous
Drugs had for nearly 40 years, until 1968, the
same quota of 300 agents and the same budget
as when that agency was founded. Narcotic offi-
cers are so rushed that many times there appears
a laissez faire attitude toward the user and a con-
centration only on source of supply. It is equally
important that the user, as well as the seller,
know the consequences of narcotic law violation,
and there must be vigorous pursuit of the illegal
drug consumer.

(5) Just as there must be legal deterrents on
the user of drugs and a price paid for proved use
or possession, so must there be an avenue of vol-
untary withdrawal. Such alternative is available
through youth crisis centers, sanctuaries with legal
immunity where a drug user can seek and find
with amnesty, treatment for the acute physical ills
of drug usage, therapy for the emotional lameness
which contributes to drug dependency, and there
must be available referral to long range services.
Many addicts are earnestly seeking a bridge back
to normal life and youth crisis centers can serve
as one of society’s expressions of concern and
help.

(6) Too much time is spent in the debate be-
tween advocates of long and short term sentences
for addicts. The length of time segregated from
society is not nearly as significant as the nature
of confinement. There are situations in which the
present use, possession and sale sanctions are ab-
solutely essential, but there are also cases in
which probation and treatment are indicated.

Recently, in San Antonio, Texas, a heroin ring
was broken and 92 pounds of pure heroin was
confiscated. This haul represents 25 million dol-
lars on the drug market. Those arrested could
hardly be considered fit subjects for probation or
short term sentences.

Right now, in this county, Mississippi’s first
heroin traffic case is being prosecuted. I do not
propose leniency here. Unless we deal effectively
with young persons caught in the early stages of
experimentation they might easily graduate from
use to sale, from marijuana to heroin. Lest I be
accused of contributing to false drug information
let me say categorically here that there is docu-
mented proof of correlation between marijuana

use and subsequent heroin addiction. A California
study during the period from 1960 to 65 estab-
lished that one out of eight persons convicted of
marijuana use were also convicted of using heroin
within five years thereafter. Smugglers from Mex-
ico supply an estimated 800,000 marijuana users
per year. What will the heroin picture be five
years from now? We must not relax our present
sentencing structure for drugs, including mari-
juana, but we must place treatment alternatives
within the grasp of trial judges.

(7) In the field of drug addiction as in the
field of alcoholism, society has such a vested in-
terest in the addicted individual that it has a right
to enforce withdrawal and treatment as an alter-
native to confinement. We cannot continue under
the assumption that only the well motivated ad-
dict can be helped. It is suggested that in this
area, as in the area of treatment of the resistive
psychotic, research can make techniques available
to change attitudes of determined users and can
fortify a resolve to abstain.

TREATMENT FACTORS

Let us be perfectly frank about one thing — the
patient is not always the only reluctant partici-
pant in the treatment process. There is a medical
factor in the treatment of practicing addicts and
alcoholics. It cannot be passed off as either a psy-
chiatric or law enforcement problem on any
moral or any professionally logical grounds. The
arbitrary unwillingness of many physicians to
treat alcoholics or drug addicts is no more de-
fensible than refusal to treat numerous other pa-
tients whose ailments are caused or contributed
to by the human will. An addict is as much en-
titled to treatment as an ulcer patient. Society has
a right to demand that an addict accept medical
treatment. What demand, if any, do the needs of
the community and the Hippocratic oath impose
upon the internist to provide that treatment?

Candor must overcome courtesy at this point.
The oldest known drug in our society is alcohol,
but the medical profession as a whole has shown
extreme reticence in tackling the basic problem
of alcoholism. Although some more fortunate al-
coholics may be admitted to some hospitals on
such veiled diagnoses as gastritis or dehydration,
alcoholic admissions to medical wards are ex-
tremely rare. Of equal significance is the attitude
of many practitioners that the acute medical
problems of alcoholism must await treatment until
sobriety is restored or until psychiatric treatment
has passed some mystical point. This does not get
the job done with the alcoholic and will succeed
even less with the drug addict.

(8) The very heart and soul of effective drug

NOVEMBER 1970

597

YOUTH AND DRUGS / Guernsey

control must lie in a long term treatment program
with a three stage course of action. The first stage,
which must be conducted under close confine-
ment, is that of physical withdrawal from drugs
and restoration of the body. This should include
treatment of organic damage including maximum
recovery from brain, liver, kidney and respiration
dysfunction. It should include a physical fitness
program approaching the program of military
service to provide the morale factor of maximum
health.

Step two, perhaps the most difficult, would be
the treatment of the emotional aspects of addic-
tion. Although every member of this audience is
more capable of evaluating this premise than I
am, it is suggested that addiction or dependency
is both a cause and an effect of emotional prob-
lems, many of them treatable. Many children with
drug problems come back from evaluation with
a diagnosis of passive aggressive personality dis-
order or adolescent adjustment reaction. With ei-
ther diagnosis, therapy has proved helpful in sim-
ilar cases. The fact that the problem has mani-
fested itself in drug experimentation does not alter
the fact that there is an underlying emotional dis-
order. How much by way of therapy must be pro-
vided in a closed ward and how much can be han-
dled on an outpatient basis, conceivably in a com-
munity mental health clinic, remains to be seen.

The third and final stage of the treatment proc-
ess is to train or re-train the addict for successful
participation in society. Addiction strikes many
at such an early age that it cuts off the individu-
al's preparation for a life work. Often the addict
is an excessively bright person equipped by edu-
cation to be no more than a service station at-
tendant or a short order cook. Such a person is
destined for frustration and could be expected to
seek escape from what he sees as life’s cruelty in
the pleasurable anesthesia he once knew. I do not
suggest that vocational training is the only essen-
tial of the process of returning addicts to society,
but it is a most significant one.

Other problems in re-socialization of the addict
would be the establishment of acceptable pastimes
and the formation of new contacts, possibly
through such groups as a synanon, the addict’s
equivalent of Alcoholics Anonymous. Total resto-
ration would be different in every case and would
depend upon multiple variations of physical, men-
tal, emotional and spiritual support.

(9) The ninth and final step in a total drug
control program would be an after care program
for addicts with some of the components of the
present parole system. Just as a parole from pris-
on is now a conditional privilege, release from a
treatment center should also be. We should not
hesitate for the sake of society and the individual
user to utilize Naline which causes immediate
withdrawal syndrome or polygraph tests to deter-
mine that the user does not revert to old practices.
It is postulated that individuals with defective
conscience can find reinforcement for abstinence
from the certainty that use would be detected.

The program which is blueprinted here is one
of unquestionable expense. It is also one which
calls for a re-thinking of legal and medical con-
cepts. To such truths I can only say that the alter-
native is even greater economic loss, chaos and
the destruction of multiplied thousands of human
lives.

We must not fall into pitfalls which have
threatened our approach to other social problems.
There is no quick and easy solution to the drug
problem nor is there a miracle cure for drug ad-
diction. At the same time, this problem is of such
major proportion that we cannot afford the luxury
of punitive self-righteousness. We cannot punish
our national drug problem out of existence any
more than we can hide our heads ostrich-like in
the sand and say we have no problem.

I do not suggest that the blueprint which I have
set forth is a panacea for drug abuse. I do pro-
pose it as a beginning point in a comprehensive
plan to deal effectively with a major social crisis
confronting the American people. ***

4729 Kings Highway (39201)

BAGGAGE CLAIM

Upon landing on the moon and surveying the situation, one
astronaut quipped to the other: “Even though our technology has
advanced remarkably, I’m happy to see one feature of our
government hasn’t changed since World War II. Here we are
on the moon and our supplies are on Venus.”

598

JOURNAL MSMA

the case against
chiropractic

J'-

,

-f

Who are they? Why are they rejected by the medical
profession? What exactly is the cult of chiropractic?

Learn the answers to these questions and many more
from a startling new book by renowned medical jour-
nalist and public affairs specialist, Ralph Lee Smith.

AT YOUR OWN RISK: The Case Against Chiropractic is
a probing study of chiropractors and their methods of
treatment. It follows the history of chiropractic from
its conception by an Iowa grocer in 1895 to present
day practices.

Travel with Mr. Smith as both patient and visitor to
many of the nation’s chiropractic schools and clinics.
And learn why he recommends that chiropractic be
the subject of immediate legislative review.

Available from the AMA through special arrangements
with the publisher. Send your order to the AMA, 535
North Dearborn Street, Chicago, Illinois 60610.

I enclose $.

.for.

copy(s) of At Your Own Risk:

The Case Against Chiropractic.

U.S., U.S. Poss.
Mexico, Canada

□ Hardbound

OP-47, 184 pages $4.00

Medical Students,
All Other Hospital Interns,
Countries and Residents*

$4.50

■ . ■■

□ Paperbound

OP-22, 184 pages $1.00 $1.50

Quantity order prices available on request.
Name

$2.00
$ .50

Address

City/State/Zip

Payment must accompany order.

♦Special subsidized rate available in U.S., U.S. Poss.. Canada
and Mexico only.

Radiologic Seminar Cl
Roentgen Changes in the Sella Turcica

in Pituitary Tumors

The location of the pituitary gland in relation
to the sella turcica is such that a pituitary tumor
can readily produce changes in the sella which can
be demonstrated on plain skull films.

The vast majority of pituitary tumors are ade-
nomas, either chromophobe in type or chromo-
philic in type. The chromophilic adenomas may
either be of the acidophilic or basophilic type and
make up about 20 per cent of these tumors.
Chromophobe adenomas make up about 80 per
cent of the tumors. Adenocarcinoma and adaman-
tinomas of the pituitary gland may occur, but they
are rare.

The roentgen findings are the result of pres-
sure atrophy caused by direct contact with the
tumor. Basophilic and acidophilic adenomas may
cause marked symptoms without demonstrable
changes in the sella. Chromophobe adenomas can
also be large enough to produce neurological
signs, especially from pressure on the optic
chasma, without producing x-ray changes in the
sella.

A typical early deformity is simultaneous
atrophy of the dorsum sella and the floor of the
sella turcica. The dorsum first becomes thinner
and more concave and appears pushed backward
causing an increase in the sagittal dimension of
the fossa. This then may go on to complete de-
struction of the dorsum and the posterior clinoid
process. At the same time the floor of the sella
becomes thinner and more depressed and finally
encroaches on the sphenoid sinus. The tumor may
produce changes on one side more than the other.
The anterior clinoid processes do not, as a rule,
share in bone atrophy in connection with pituitary
tumors.

Sponsored by the Mississippi Radiological Society.

From the Department of Radiology, Houston Hospital,
Inc.

LYNDON M. CONLEY, M.D.

Houston, Mississippi

Calcification can occur in pituitary adenomas.
Malignant tumors tend to be more rapid in growth
and to destroy by infiltration.

Clinically, hypopituitarism is usually associ-
ated with chromophobe adenomas. In children,
this results in pituitary dwarfism. In adults, there
is loss of energy, easy fatigability, and lack of
libido. There is also frequently a superior quad-
rant defect in the temporal visual field followed
by progressive changes and finally a loss of vision.

Pituitary acidophilism in childhood results in
gigantism. In adults, there is acromegaly.

Figure 1. Note erosion of floor of the sella and
destructive changes in anterior and posterior clinoids.

Pituitary basophifism results in a particular
symptoms complex identified by rapid and pain-
ful obesity, hypertrichosis and amenorrhea, high
red blood cell count, high hemoglobin, high blood
pressure, kyphosis, abdominal purplish stiae, high
cholesterol, glycosuria, and general osteoporosis.
The syndrome is more common in females.

600

JOURNAL MSM A

Figure 2. Note rounding of the sella turcica, un-
dermining of the anterior clinoid process and thin-
ning of the dorsum sella, producing so-called “bal-
looning.”

It should be noted that changes in the sella
turcica are not limited by any means to tumors of
the pituitary gland, although pituitary tumors are
the most common cause of enlargement of the
sella. Craniopharyngiomas (Rathke pouch tu-
mors), suprasellar or tuberculum sella meningio-
mas, and aneurysms of the adjacent intracavern-
ous portion of the internal carotid artery may also
produce enlargement and destruction of the sella.
Also, dilatation of the third ventricle with in-
creased intracranial pressure may produce these
changes.

Recognition of gross changes in the sella tur-
cica is usually an easy matter. More subtle, earlier
changes may easily be overlooked unless one
measures the sella. Normally on the lateral x-ray
the greatest anteroposterior diameter in the
adult will not exceed 17 mm., and the depth will
not be greater than 13 mm. Other measurements
including area calculations may be informative in
borderline cases. Also, one must not loose sight
of the fact that borderline cases of enlargement,
without symptoms pointing to a lesion in this
area, exist. In most of these cases further investi-
gation by arteriography and pneumoencephalog-
raphy will reveal no evidence of abnormality.

Following are three example of x-ray findings
in pituitary tumors:

Case No. 1. This patient was originally seen
because of injury and the skull x-rays showed ex-
tensive changes in the sella turcica. There is noted
erosion of both anterior and posterior clinoid
processes and erosion of the floor of the sella.

3. Note extensive destructive changes in dorsum
and posterior clinoid process. Also demonstrated is
enlargement of the paranasal sinuses commonly seen
in acromegaly.

The patient apparently gave a history of progres-
sive loss of vision over a period of time.

Case No. 2. This patient presented symptoms
of acromegaly. This sella turcica does not show
as extensive changes as in Case No. 1. The
changes in this case are seen mainly as erosion
of the floor of the sella turcica. Also, in this case,
the findings appear to be more pronounced on
one side than on the other. Arrows outline the
floor of sella.

Case No. 3. The patient also presents clini-
cal findings of acromegaly. Here again, there are
extensive changes in the sella turcica. The dorsum
and posterior clinoid processes snow evidence of
destruction, and also the flood of the sella, while
the anterior clinoid processes appear intact.

In conclusion, the pituitary gland is located in
an area where a tumor can produce changes in
the sella turcica which can be of diagnostic sign-
ificance on plain films of the skull, although tu-
mors of the pituitary can cause clinical findings
without appreciable changes in the sella turcica.

★★★

Hwy. 8 East (3885 1 )

REFERENCES

1. Eugene P. Pendergrass, M.D.; J. Parsons Schaeffer,
M.D. and Phillip J. Hodges, M.D.: Head and Neck
in Roentgen Diagnosis, 2nd Edition, Vol. II, Pages:
950-971. ~

2. Alfred A. De Lorimier. M.D.; Henry C. Moehring,
M.D. and John R. Honnan, M.D.: Clinical Roentgen-
ology, Vol. II, Pages: 149-153.

3. Paul F. J. New, M.D.: The Radiological Clinics of
North America, April 1966, Pages: 75-91.

NOVEMBER 1970

601

The President Speaking

‘A Busted Play?’

PAUL B. BRUMBY, M.D.
Lexington, Mississippi

During the 1970 football season, we have seen the busted
play which, on occasion is turned into a gain by an alert offense.
This is a fair description of consideration of H.R. 17550, the
Social Security Amendments of 1970, now before the Senate
Finance Committee after passage by the House of Representatives.
We are concerned with amendments to Titles V (Maternal and
Child Welfare Grants), XVIII (Medicare) and XIX (Medicaid).
Especially are we interested in peer review, a program of Amer-
ican medicine to which the Congress has taken a liking.

Sen. Wallace Bennett (R., Utah), basically a conservative,
introduced Amendment No. 851 to the bill, providing for a Pro-
fessional Standards Review Organization. Apart from this, he is
a cosponsor of AMA’s Medicredit and PRO, the kissing cousin
to his PSRO. It is in the latter that medicine has found reason
to record objections. PSRO, while maintaining in principle the
concept of physician review of medical services, goes too far and
is too punitive in certain aspects.

AMA’s testimony hit hard on points of objection: Limiting
peer review to physicians’ services and not including those of
other providers, i.e., hospitals, dentists, etc.; the punitive provi-
sions, including fines for infractions; and the requirement for prior
approval in admissions for elective procedures.

The Senate Finance Committee receded from most of this hard
line position by limiting physician review to medical services
by physicians, substituting “professional persuasion” as the first
resort for blatant misuse instead of fines, and by eliminating
the prior approval requirement, leaving the matter in the hands
of the review organization. Still dangling are the composition of
the review body and priority to state medical associations in
determining who shall perform this task.

We should support AMA’s position and give new and impor-
tant impetus to the Mississippi concept of peer review approved
by our House of Delegates and implemented by our competent
Committee on Peer Review. This is one busted play which can
be turned into a touchdown. ***

602

JOURNAL MSM A

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 11
NOVEMBER 1970

Mississippi Peer Review:
The Practicing M.D.’s Own Plan

I

Peer review is the newest American medical
household word. It has no hidden or surreptitious
meanings, no clandestine connotation, nor sub-
versive intent. As far as the Mississippi State
Medical Association is concerned, peer review
means what it says: Physicians’ managing their
own house with review of the quality and costs of
medical care.

At the 102nd Annual Session in May 1970,
peer review was the most-discussed and voted on
issue before the House of Delegates. It was the
heart of the president’s address and the subject
of a supplemental report of the Board of Trustees.
Open debate on it was conducted before the best-
attended reference committee, and the delegates
voted on it, directly and indirectly, three times.
All votes were overwhelmingly affirmative with
no opposition recorded.

The House of Delegates created a constitu-
tional Committee on Peer Review and gave it one
of the most massive assignments ever handed to
a committee. The nine-member body, geograph-
ically apportioned by association districts so as
to be representative of the practicing profession,
has conducted four meetings, despite the fact that
the 1970-71 association year has not yet reached

the half-way mark. The committee has reached
out to touch elements of the health care team and
voluntary and government financing mechanisms
which have never before had liaison with the
association.

Peer review is a going concern in Mississippi,
operating under association aegis, association def-
initions, association policies, and physician leader-
ship. But recent legislation before the final hours
of the 91st Congress has stirred some doubts
about peer review, and regrettably, much mis-
information about it has been circulated. In most
instances, this is a matter of misunderstanding.
The time has come to restate association policy
as established by the House of Delegates and to
describe constructive effort and work by the new
committee. In brief, we are going to clear up peer
review pollution and get on with the job.

II

“Cur names are labels, plainly printed on the
bottled essence of our past behavior,” wrote
Logan Pearsall Smith. For American medicine,
peer review is nothing new. In 1955, the griev-
ance committee mechanism, designed to prevent
and resolve differences between physician and
patient was standardized among almost all medi-

NOVEMBER 1970

60 3

EDITORIALS / Continued

cal societies. In 1968, fee review was approved
by the state medical association. The following
year, peer review began to take shape under the
leadership of Dr. James L. Royals, the 1969-70
president.

“Within our own ranks,” Dr. Royals said, “we
must develop a working system of peer review as
an effective instrument of self-regulation. The un-
acceptable alternative — and it is virtually upon
us — is submission to third parties who would
sit in judgment upon the quality of care and the
price paid for it.”

The president emphasized that “physicians are
best equipped to make these judgments, but we
must make responsible and worthy judgments if
we are to have them accepted.”

“Perhaps most important of all,” Dr. Royals
reminded, “is the thrust of peer review which is
not punitive but educational and corrective. We
must learn to work in harmony with peer re-
view and honor the judgments of our colleagues.
Otherwise, we shall certainly be judged by
others.”

Frequently, Dr. Royals said in speeches, pre-
sentations to the Board of Trustees, and even in
conversation that he “wanted no insurance com-
pany or third party judging me and my profes-
sional services. I want other physicians to review
my services to my patients.”

This, then, is the Mississippi State Medical As-
sociation Peer Review program which combines
the functions and responsibilities of the old
grievance committee, the fee review activity, and
now the umbrella of peer review for quality, de-
livery, and cost of care. The association defini-
tion, since formalized in the By-Laws, includes
but is not limited to resolution of differences be-
tween patient and physician, review of the qual-
ity of medical care, adequacy and/or reason-
ableness of fees whether due or paid from pri-
vate or public sources, and liaison with private
and public sources of medical care financing.

In its special report which was approved by the
House of Delegates, the Board of Trustees of-
fered precise definitions: “Peer review operates
essentially in two areas, scientific and economic.
Scientifically, we are concerned with the quality
of medical care. We are interested in the orga-
nization and delivery of care and availability and
accessibility. We are just as interested in prob-
lems of underutilization of health care resources
as we are in overutilization, a wasteful drain on
manpower, facilities, and funds.

“Economically,” the Board continued, “peer

review is a two-way street. We are interested in
fair and just compensation for quality services
rendered, preferably under the concept of usual
and customary fees which we have also en-
dorsed. We are equally concerned when there
is reason to believe that excessive charges have
been made or when any charge relates to what
physicians may determine to be an unnecessary
service. We are interested in proper and optimum
and maximum benefit use of the health care dol-
lar, whether personal and out-of-pocket or from
tax (public) sources.”

Almost no major program of the association
has been implemented so rapidly or so com-
petently as the peer review project. And it has
been done under an association-forged program
by association members in a constitutional
frame of reference and crystal clear policy es-
tablished by the House of Delegates.

Ill

Enter now upon the American medical scene
H.R. 17550, the Social Security Amendments
of 1970, which is concerned in no small way
with Medicare and Medicaid. The combined fed-
eral tab on these programs is about $15 billion
per year, and they have extended the medical
care purchasing base by almost 40 million Amer-
icans. It is not in the least astonishing that the
Congress would have a logical concern about get-

604

JOURNAL MSMA

ting the most for the public health care dollar.

AMA’s Medicredit bill (Medicredit: Delivery
System in AMA’s Image, J.M.S.M.A. XI:69-71
(Feb.) 1970) took this into account by propos-
ing a Peer Review Organization (PRO) under
state medical association control and sponsorship.
Since introduction of the measure, a separate
PRO bill has been dropped into the hopper with
nearly 30 Congressional sponsors.

Meanwhile, H.R. 17550 cleared the House of
Representatives and went to the Senate where
Sen. Wallace Bennett (R., Utah) offered Amend-
ment No. 851 which would establish a Profes-
sional Standards Review Organization (PSRO).
The Bennett amendment, while closely parallel
to AMA’s PRO, has some rough edges and puni-
tive provisions. Nobody in the Senate, no mem-
ber of the Senate Finance Committee which re-
ceived the bill and amendment, and especially
Sen. Bennett himself expect Amendment No. 851
to be enacted into law as initially drafted.

In testimony before the committee, Dr. Wil-
liam O. LaMotte, Jr., of Wilmington, Del., chair-
man of the AMA Council on Legislation, made
medicine’s objections to portions of the amend-
ment quite clear. He asked that priority on con-
tracts with state medical associations for PSRO
activities be mandatory, as opposed to contracts
with “medical societies.” He asked that composi-
tion of the PSRO be specified, as it is in AMA’s
PRO.

Dr. LaMotte objected to prior authorization
for elective procedures, and he found the puni-
tive provisions unacceptable. Moreover, the AMA
testimony stressed, PSRO reviews the full spec-
trum of health services, whereas PRO is con-
cerned only with physicians.

That the AMA testimony was effective is seen
in changes made in PSRO. The prior authoriza-
tion requirement for elective procedures was
sacked, and separate review mechanisms were au-
thorized for each provider field, i.e., physicians
reviewing physicians and dentists reviewing den-
tists. “Professional persuasion” was prescribed
for findings of unnecessary surgery or overuti-
lization of hospital facilities as a measure of first
resort — not punitive measures.

While these processes were developing, some
became apprehensive about the Bennett amend-
ment, forgetting for the moment that the senator
from Utah is no wild-eyed liberal. His intention
parallels that of AMA. It has been a matter of
adjusting viewpoints, clarifying language in pro-
posed law, and bringing together the parties at
essential interest in the medical care plans af-
fected.

IV

What began as a logical extension of grievance
and fee review committee activity suddenly found
itself in federal and federally-assisted health care
plans. All of this is to say that peer review is for
real, and it is rapidly becoming a matter of fish
or cut bait for state medical associations. Nobody
should be surprised that where a state medical
association is unwilling or unable to conduct its
own peer review, the Secretary of HEW will do
it for the organization.

The few who became overly alarmed at the
Bennett amendment made their fears known be-
fore the Senate Finance Committee hearings were
complete or the tentative position of the commit-
tee was announced. One state medical association
called a special session of its House of Dele-
gates before the hearing was conducted and con-
demned peer review.

But here in Mississippi, the association has
acted with foresight and prudence. The clear-cut
policy, the sound organization under the Commit-
tee on Peer Review, the stability of leadership,
and a host of sensibly planned and executed ac-
tions make the Mississippi peer review system one
to be emulated. In Dr. Royals’ words, we are on
our way to being masters of our own house. —
R.B.K.

Be Sure to Answer
NORC’s Call

Four thousand two hundred American physi-
cians in private practice may soon be interviewed
on costs of health care and use of medical ser-
vices by their patients. It is all part of a land-
mark study by the Center for Health Administra-
tion Studies and the National Opinion Research
Center (NORC) of the University of Chicago.
AMA has endorsed the project.

NORC is initiating its fourth study of care
cost and use of medical services by American
families. The purpose is to measure the effective-
ness of health insurance, commercial and Blue
plans, in meeting the costs of care. Only those
families purchasing medical care in the past year
will be in the sample. When, in the course of the
family interview, a physician’s name is mentioned,
the research organization will ask the inter-
viewee’s permission to query the doctor.

The NORC interviewer will present the phy-
sician a letter of introduction and endorsement
from Dr. Ernest B. Howard, executive vice pres-
ident of AMA. Information sources, identity of

NOVEMBER 1970

605

EDITORIALS / Continued

those interviewed, and information derived from
the sessions, are, of course, held in strict con-
fidence.

As some physicians know, these insurance ef-
fectiveness studies are not new. NORC has con-
ducted three, in f 95 3 , 1958, and 1963, and they
have become standard references on authorita-
tive information on health insurance effective-
ness. The interview of families selected in the
sample will be comprehensive and lengthy. Not
so with the physician interviews which are more
in the nature of verification inquiries.

The support of Mississippi physicians is re-
quested in this project which will be immensely
valuable to American medicine, voluntary pre-
payment, and insurance carriers in measuring the
impact of voluntary health care financing on
costs. When the doorbell rings, if it’s NORC in-
stead of Avon calling, we ask your help. — R.B.K.

The Passing
of the Panama

The Panama Limited, perhaps the last of the
nation’s great passenger trains, will be no more
after Nov. 23. The passing of the Panama hardly
seems a fit subject for editorial comment in a
medical journal, but this train has figured prom-
inently in the lives of hundreds of Mississippi
physicians.

Consider how, during the 40-odd years that Nos.
5 and 6 of the Illinois Central Railroad plied the
Main Line of Mid-America, many Mississippi
M.D.’s and their families regarded it as the only
way to and from a Chicago medical meeting.
How many more medical students, now in prac-
tice, savored the luxury of Panama transporta-
tion between New Orleans, Memphis, St. Louis,
and Chicago and their respective Mississippi
homes?

And consider the impressive list of IC surgeons
from McComb City (as the conductor always
said) all the way up to Batesville who cared for
the crews and maintenance teams. In fact, it was
an unusual night when there wasn’t a physician
headed north on the Panama or when no M.D.
checked in at the first gate in the just-south Chi-
cago IC station.

The Panama Limited is a victim of progress,
shifting values, and changing times. During 1969,
operation of the train lost $1 million for the IC,
and equipment obsolescence is another prime con-

606

sideration. The two train units, diesels and cars,
are 25 years old. Despite excellent — and expen- 1
sive — maintenance, they need replacing, and the
tab on this is $7 million. 1C officials point out
that they haven’t that kind of investment capital
to put into a losing proposition.

To many Mississippians, the Panama is more
of an institution than a common carrier. Luxury
and personal service were the bywords during
the happy, halcyon hours of travel in the all-
Pullman streamliner. The cheerful, competent
porters and waiters took pride in long service and
professionalism. The bedroom was invariably im-
maculate, and you always wondered how the lug-
gage got there ahead of you with bags neatly
stowed away and coats hung on real wood hang-
ers.

Then there was the club car, the complimentary
Kauna cheese with the refreshments, and a handy
copy of the Times Picayune or Chicago Tribune
to peruse. Dinner was a state occasion on the
two-car diner with crab fingers, Great Lakes
whitefish, and a charcoaled steak two inches
thick. And as at the auberge adjacent to the gour-
met restaurants in Lyons, the bed was turned
down for the well-nourished traveler upon return
to the Pullman.

Breakfast was no less a ceremony of good ser-
vice and excellent food. The steaming coffee,
thick French toast with real maple syrup, the

“That’s the third one this week. O' Brian. . . . We
make a pretty good team.”

JOURNAL MSMA

morning papers, and gleaming silver on flawless
napery started the day just right. Overnight, the
shoes had been shined, too.

Just how, if all this is true, can a mobile pop-
ulation let the Panama pass away? Time and
schedule pressures are the primary reasons, be-
cause Delta and Southern require only two hours
to do what the Panama did in 14 hours. And
there is the matter of transportation economics:
A single DC-9 jet can carry more passengers be-
tween Chicago and New Orleans in a week than
both Panamas can in a month — for much less
money, too.

American railroads, unquestionably the win-
ners of the west in the 19th century, haven’t had
a fair shake in the 1900’s. Whereas the air lines
enjoy the use of modern terminal and airport
facilities built by cities with federal aid, the rail-
roads must purchase their right-of-way, build and
maintain tracks, and pay taxes on the whole she-
bang.

The air lines enjoy use of the world’s best high-
way system with 100 per cent federally financed
and supported VOR navigation facilities and
terminal radar. The railroads buy, install, and
operate their own communications and signal sys-
tems, just as they must provide for “terminal”
facilities in stations. Almost half of the team back-
ing up the jet are on the federal payroll, but about
the only federal salary implicit in the railroad pic-
ture is that of the U. S. district attorney who sues
it.

So the passing of the Panama convokes a happy
and simultaneously sad nostalgia as it marks the
end of an era. It also reminds us that transporta-
tion economics need a second look. — R.B.K.

Bloody Tort: Liability
Without Negligence

The Illinois State Supreme Court has shaken
up hospitals and physicians in its decision in
Cunningham v. MacNeal Memorial Hospital. The
tribunal applied the products liability doctrine
to blood supplied for human transfusion, even
though no negligence was involved.

The suit was brought when one Frances Cun-
ningham sought damages for blood received
which caused hepatitis. The trial court found for
the defendant hospital which had not been negli-
gent. On appeal, the Supreme Court found for
the plaintiff, stating that “it is no defense for the
hospital to show that it had done everything pos-
sible to preclude the existence of the virus." By
remanding the case to the lower court for retrial

under strict tort liability doctrine in product litiga-
tion, the high court defined blood as a product
and not a service.

Mississippi was one of the first four states
to secure a legislative enactment defining blood
transfusion as a service and not a sale. The doc-
trine, therefore, would not and could not apply
here. Altogether, 25 states have this vital law
on the books. Illinois, unfortunately, does not.

Bernard D. Hirsh, general counsel of AMA,
said that “this doctrine, applied previously to
commercial products, imposes liability for un-
limited damages for injuries caused by a defec-
tive or contaminated product, regardless of wheth-
er the defect or contamination was caused by
negligence, and regardless of whether it is pos-
sible to prevent the defect or contamination.

“As applied to blood for transfusions,” Mr.
Hirsh continues, “this doctrine would appear to
create a serious financial hazard in the use of
blood for transfusions in medical care. Even if
insurance protection can be obtained, it seems
likely to have a substantial effect of increasing
the general cost of medical care.”

Both the Illinois State Medical Society and
Illinois Hospital Association went to the Supreme
Court in the case as amici curiae or friends of
the court who had a substantial interest in the
outcome of the case. As it turns out, they did,
because hospitals and physicians stand naked and
virtually defenseless before the decision, easy prey
to damage suits even where no negligence is pres-
ent. And exactly half of the states have a new
reason for concern in tort liability. — R.B.K.

Sen. Eastland Helps
the Chiropractors

It is disquieting to learn that Sen. James O.
Eastland, the respected and powerful leader in
the U. S. Senate, cosponsored a bill to include
the services of chiropractors under Medicare’s
Part 1-B. In fact, there is every reason in the
world for the senator to withhold his immense
prestige and influence from such, because he rep-
resents one of the two states which refuse to place
the badge of respectability and legality on this
cult.

But it is true, because Sen. Eastland has joined
as a cosponsor with Sen. Clinton Anderson (D.,
N. Mex.) for S. 1812, “a bill to amend Title
XVIII of the Social Security Act so as to include
chiropractors’ services among the benefits provided
by the insurance program established by Part B
of such title.”

NOVEMBER 1970

607

EDITORIALS / Continued

There is further reason for the senator’s having
avoided this action: Just about every agency, or-
ganization, and individual with the smallest modi-
cum of interest in health care delivery have de-
nounced chiropractic for the quackery it is.

The AFL-CIO opposes chiropractic, as does
the Senior Citizens of America. President Nixon’s
Task Force on Medicaid and Medicare slammed
the cult. The National Advisory Commission on
Health Manpower gave the spine punchers the
shaft, and even former HEW Secretary Wilbur
J. Cohen, hardly the president of the AMA fan
club, denounced it with a fervor difficult to de-
scribe and a logic impossible to refute.

The House Committee on Ways and Means
turned the cultists away, and HEW has recom-
mended to the Congress that “a legislative amend-
ment should be enacted denying financial partici-
pation in Medicaid payments to chiropractors. . .

The American Chiropractic Association, re-
porting its 1970 national convention in Hawaii,
said in its journal that “to help make the conven-
tion a successful one and to give cause for extra
celebration, convention goers were treated to the
good news that U. S. Senator James Eastland of
Mississippi had cosponsored S. 1812 now being
considered by the U. S. Senate for chiropractic
inclusion in Medicare.”

The chiropractors were so ecstatic about the
powerful Mississippian that they failed to mention
the name of Sen. Anderson, their legislative angel,
at all.

We hope that Sen. Eastland, who has always
commanded our respect and admiration for his
exercise of statesmanship, will withdraw his in-
fluential endorsement from this harmful proposal.
— R.B.K.

Pediatric Heart
Disease Course Slated

“Congenital and Acquired Heart Disease in In-
fants and Children,” a pediatric cardiology post-
graduate course, will be presented by the Amer-
ican Academy of Pediatrics and the Department
of Pediatrics of the University of Florida Col-
lege of Medicine, Dec. 9-12, 1970.

The seminar will convene at the Happy Dol-
phin Inn, St. Petersburg Beach, Fla. Inquiries
and requests for registration forms should be di-
rected to Dr. Gerald Hughes, Secretary for Edu-
cational Affairs, American Academy of Pediat-
rics, P. O. Box 1034, Evanston, 111. 60204.

I

November 4, 1970

Thromboembolic Disease: The pClot That
Kills

University Medical Center, Jackson
November 4, 1970, beginning at 9:30 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Participants:

Kenneth R. Bennett, M.D., assistant professor of
medicine, The University of Mississippi School
of Medicine, and director of the coronary care
training program, Mississippi Regional Medical
Program

H. Davis Dear, M.D., assistant professor of medi-
cine, The University of Mississippi School of
Medicine

C. Jay Kees, M.D., instructor in radiology, The
University of Mississippi School of Medicine

John D. Morgan, M.D., instructor in medicine,
The University of Mississippi School of Medi-
cine

Francis S. Morrison, M.D., associate professor of
medicine and instructor in clinical laboratory
sciences, The University of Mississippi School
of Medicine

Joe Robert Norman, M.D., professor of medicine,
Christmas Seal professor of respiratory dis-
eases, and associate professor of physiology
and biophysics, The University of Mississippi
School of Medicine

Roland B, Robertson, M.D., assistant professor
of medicine, The University of Mississippi
School of Medicine

Arthur A. Sasahara, M.D., assistant professor of
medicine, Harvard Medical School, Boston,
Massachusetts; assistant chief, Medical Ser-
vice, and director, Cardiopulmonary Labora-
tory, Veterans Administration Hospital, West
Roxbury, Massachusetts

Hiliary H. Timmis, M.D., associate professor of
surgery, The University of Mississippi School of
Medicine

T. Walter Treadwell, M.D., assistant professor of
medicine, The University of Mississippi School
of Medicine, and associate director of the
chronic pulmonary disease training program,
Mississippi Regional Medical Program

Henry B. Tyler, M.D., clinical instructor in sur-
gery, The University of Mississippi School of
Medicine

608

JOURNAL MSMA

Myra Tyler, M.D., associate professor of medi-
cine and director of pulmonary research, The
University of Mississippi School of Medicine,
and director of the chronic pulmonary disease
training program, Mississippi Regional Medical
Program

Wednesday Morning

Clinical Setting
Dr. M. Tyler

Anticoagulants: Old and New
Dr. Morrison
Diagnosis

Dr. Sasahara
Sandwich Seminars

Anticoagulation — Dr. Morrison
Bedside Diagnosis — Dr. Treadwell
EKG and Pulmonary Embolism — Dr.
Bennett

Surgical Therapy — Dr. Timmis
Treatment of Thrombophlebitis — Dr.
H. Tyler

Blood Gasses — Dr. Morgan
Pulmonary Arteriography and Scans —
Dr. Kees

Enzymes — Dr. Robertson
Wednesday Afternoon

Pathophysiology
Dr. Norman
Current Therapy
Dr. Sasahara
Prophylaxis
Dr. Dear

December 11 , 1970

Infections in Obstetrics and Gynecology
Seminar

University Medical Center, Jackson
December 11, 1970, beginning at 8:50 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Center for Disease Control. U. S. Public Health
Service

Participants:

Alfred W. Brann, Jr., M.D.. assistant professor of
pediatrics, assistant professor of medicine, in-
structor in physiology and biophysics, and di-
rector of newborn services, The University of
Mississippi School of Medicine
John Kitchings, M.D., clinical assistant professor
of obstetrics and gynecology, The University of
Mississippi School of Medicine
James Lucus, M.D., assistant to the chief. Ve-
nereal Disease Branch, Center for Disease Con-
trol, Atlanta. Georgia

John Sever, M.D., head, Section on Infectious
Diseases, Perinatal Research Branch, National
Institute of Neurological Diseases and Stroke,
National Institutes of Health, Bethesda, Mary-
land

Donald Sherline, M.D., associate professor of
obstetrics and gynecology and instructor in
anesthesiology, The University of Mississippi
School of Medicine

Henry A. Thiede, M.D., assistant dean, professor
of obstetrics and gynecology, and chairman of
the department, The University of Mississippi
School of Medicine

William Wiener, M.D., clinical associate professor
of obstetrics and gynecology, The University of
Mississippi School of Medicine

Gary Wood, M.D., assistant instructor in ob-
stetrics and gynecology, The University of Mis-
sissippi School of Medicine, and senior resident,
University Hospital

Robert Yelverton, M.D., assistant instructor in
obstetrics and gynecology, The University of
Mississippi School of Medicine, and senior
resident, University Hospital

Friday Morning

Current Diagnosis and Therapy: Gonorrhea
Dr. Lucus

Pelvic Inflammatory Disease
Dr. Wood

Vaginitis and Cervicitis
Dr. Wiener

Panel: Venereal Disease

Dr. Lucus, Dr. Wiener, Dr. Wood

Viral Disease in Pregnancy
Dr. Sever

Friday Afternoon

Septic Abortion
Dr. Yelverton

Antibiotic Therapy During Pregnancy
Dr. Thiede

Panel: Premature Rupture of Membranes
Dr. Kitchings, Dr. Brann. Dr. Sherline

MISSISSIPPI POSTGRADUATE

INSTITUTE IN THE MEDICAL

SCIENCES

November 30-December 4, 1970

Cardiology Intensive Course
University Medical Center. Jackson
November 30, December 1, 2, 3, 4, 1970, be-
ginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Reginal Medical Program

NOVEMBER 1970

609

POSTGRADUATE / Continued

Coordinator:

Patrick H. Lehan, M.D., professor of medicine
and Mississippi Heart Association William D.
Love research professor of cardiology, The
University of Mississippi School of Medicine
This one-week intensive course is designed
to familiarize family physicians with current
concepts in bedside diagnosis of heart disease,
aided by pulse tracings, photocardiograms,
electrocardiograms, x-rays, and hemodynamic
data. Participants will round, observe cardiac
catheterizations and join the cardiovascular
team’s discussions on management of patients.

November 30-December 4, 1970, and

January 11-15, 1971

Neurological Diseases and Stroke Intensive
Course

University Medical Center, Jackson
November 30, December 1, 2, 3, 4, 1970, and
January 11, 12, 13, 14, 15, 1971, begin-
ning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine, with the support of the
Mississippi Regional Medical Program

Coordinators:

Robert D. Currier, M.D., professor of medicine
(neurology), The University of Mississippi
School of Medicine, and co-director of the
demonstration stroke unit, Mississippi Regional
Medical Program

Robert R. Smith, M.D., associate professor of
neurosurgery, The University of Mississippi
School of Medicine, and co-director of the
demonstration stroke unit, Mississippi Regional
Medical Program

This one-week intensive course, one of the
seven Mississippi Postgraduate Institute in the
Medical Sciences courses to be offered twice
this year, features management of acute stroke
patients, acute head injuries, seizure problems
and other neurological and neurosurgical dis-
orders. Participants will attend seminars, rounds
and discussion groups, with special emphasis
on day-to-day care of patients in the Missis-
sippi Regional Medical Program demonstration
stroke unit.

December 7-11 , 1970

Nephrology Intensive Course
University Medical Center, Jackson
December 7, 8, 9, 10, 11, 1970, beginning at
8 a.m.

610

Sponsored by The University of Mississippi
School of Medicine, with the support of the j
Mississippi Regional Medical Program

Coordinator:

John D. Bower, M.D., assistant professor of
medicine and director of the artificial kidney
unit, The University of Mississippi School of
Medicine

Course content will emphasize the reversible
and treatable forms of kidney disease, with an
in-depth study of the management of acute
kidney failure and control of reversible fea-
tures of chronic kidney disease. Registrants
will take up management of pyelonephritis,
fluid and electrolyte problems, acid base bal-
ance and hemodialysis.

Registration in all intensive courses is limited
to five of 40 family physicians enrolled in the
Mississippi Postgraduate Institute in the Medi-
cal Sciences, a Mississippi Regional Medical
Program-supported project designed by the
University of Mississippi School of Medicine
and the Mississippi State Medical Association.

CIRCUIT COURSES

Northern Circuit

Greenville — October 29 — Session 2; November
5 — Session 3, Greenville General Hospital,

8 p.m.

Tupelo — November 17 — Session 3, North Mis-
sissippi Medical Center, 7 p.m.

Session 2 — Back Pain

Neurological Approach, Dr. Armin Haerer
Neurosurgical Approach, Dr. Robert R.
Smith

Session 3 — Modern Management of Rh Sen-
sitization

In the Mother, Dr. Calvin Hull
In the Infant, Dr. Alfred Brann

Southeast Circuit

•

Pascagoula — November 10 — Session 1, Sing-
ing River Hospital, 6:30 p.m.

Session 1 — Current Trends in the Manage-
ment of Septic Shock, Dr. William A.
Neely

Management of Breast Lumps, Dr. James
Spell

Eastern Circuit

Columbus — November 24 — Session 1, The
Downtowner Motor Inn, 6:30 p.m.

Session 1 — Surgical Aspects of Urinary Tract
Trauma, Dr. W. Lamar Weems
Topic to be announced, Dr. Tom Kilgore

JOURNAL MSMA

FUTURE CALENDAR

October 29, 1970

Circuit Course, Greenville

November 2-6

Radiology Intensive Course
Electrocardiography Intensive Course

November 4

Thromboembolic Disease: The pClot
That Kills

November 5

Circuit Course, Greenville

November 9-13

Gastroenterology Intensive Course
Pediatrics Intensive Course

November 10

Circuit Course, Pascagoula

November 17

Circuit Course, Tupelo

November 24

Circuit Course, Columbus

November 30-December 4

Neurological Diseases and Stroke In-
tensive Course
Cardiology Intensive Course

December 7-11

Nephrology Intensive Course

December 1 1

Infections in Obstetrics and Gynecol-
ogy Seminar

January 6, 197 1

Circuit Course, Biloxi

January 7

Circuit Course, Hattiesburg

January 11-15

Neurological Diseases and Stroke In-
tensive Course

January 12

Circuit Course, McComb

January 18-22

Cancer Chemotherapy Intensive Course

February 1-5

Electrocardiography Intensive Course

February 3

Circuit Course, Gulfport

February 4

Circuit Course, Hattiesburg

February 1 6

Circuit Course, Natchez

February 18

Neurology Seminar

February 23

Circuit Course, Columbus

March 1-5

Gastroenterology Intensive Course

March 3

Circuit Course, Bay St. Louis

March 4

Circuit Course, Hattiesburg

March 5

Renal Seminar

March 8-12

Nephrology Intensive Course
Cardiology Intensive Course

March 9

Circuit Course, Meridian

April 5-9

Pediatrics Intensive Course

A pril 6

Circuit Course, Meridian

April 13

Circuit Course, McComb

April 19-23

Radiology Intensive Course

April 20

Circuit Course, Natchez

A pril 2 7

Circuit Course, Columbus

May 3-6

Mississippi State Medical Association

May 11

Circuit Course, Meridian

Dempsey T. Amacker of Natchez announces
the opening of the Downtown Clinic at 304
Franklin Street for the practice of family medi-
cine and surgery.

W. J. Aycock of Calhoun City was recently
honored with a special program and luncheon by
the Calhoun City Rotary Club for his many years
of service to the community.

NOVEMBER 1970

611

PERSONALS / Continued

Tom E. Benefield, Jr., and J. R. House, Jr.,
of Gulfport announce the association of D. L.
Clippinger in the general practice of medicine
and surgery.

Theresa L. R. Buckley of Biloxi is serving as
chairman of the professional division of the Unit-
ed Fund Campaign in the Biloxi area.

E. L. Carruth and J. E. Mann of Jackson an-
nounce the removal of their offices for family
practice to 5429 Suncrest Drive.

R. J. Field, Jr., of Centreville was a guest speak-
er at a seminar on Areawide Emergency Medical
Systems in Tulsa, Okla.

E. Flechas of Natchez announces the removal
of his office of 172 Sgt. Prentiss Drive.

Ben Hilbun of Tupelo received a trophy as
winner of the dove hunt given for North Missis-
sippi Medical Center staff and friends by E. L.
King, hospital administrator.

Seven physicians were on the program of the Oct.
6 four-day clinical nursing conference sponsored
by the Mississippi Nurses’ Association at Jackson.
Participating were: W. L. Jacquith, Alton B.
Cobb, Steven Moore, William F. Kleisch,
Alfred W. Brann, Jr., Donald M. Sherline,
and Daniel H. Draughn, all of Jackson.

Joseph Kuljis of Biloxi has been awarded a
special certificate from President Richard M.
Nixon in appreciation for serving as a medical
advisor on Selective Service System Local Board
25 since 1948.

Robert L. McKinley of Tupelo, Medical Di-
rector of the Regional Mental Health Complex of
the North Mississippi Medical Center, participated
in a recent program on various phases of mental
health for the Lee County Bar Association.

Veronica M. Pennington of Jackson has been
honored by Central Medical Society for her 50
years in the American and Mississippi State
Medical Associations. She received a plaque, 50
year pin and lifetime membership in AMA and
MSMA.

Donald R. Rayner of Long Beach has been
named Chief of the Medical Staff at Memorial
Hospital at Gulfport.

Louis A. Rubenstein has opened his office for
the general practice of medicine in Spring Plaza
Shopping Center in Ocean Springs.

612

Stanley C. Russell of Jackson has been ap-
pointed chief, psychiatric service, VA Center, [
Jackson.

Edward G. Scott, Jr., of Meridian has been
appointed to the Mississippi Heart Association
Cardiopulmonary Resuscitation Committee. Oth-
er members of the committee, all CPR instructors,
are Karl Hatten of Vicksburg; Walter Rose
of indianola; T. E. Ross, III, of Hattiesburg;
M. A. Taqino of Biloxi; and Henry Tyler of
Jackson.

James T. Thompson of Moss Point was recently
recognized for 31 years of Rotarian service by
the Moss Point Rotary Club. Dr. Thompson
served as president of the State Medical Associa-
tion during 1966-67.

No reports of deaths in the association were
reported to the Journal during the month of
September, 1970.

Owens, Louis Jennings, Woodville. Born Cen-
treville, Miss., Aug. 14, 1937; M.D. University of
Mississippi School of Medicine, Jackson, Miss.,
1969; interned. University Medical Center, Jack-
son, Miss., one year; elected Sept. 1, 1970 by
Amite-Wilkinson Counties Medical Society.

Dr. Thiede Named
Assistant Dean

Dr. Henry A. Thiede, professor of obstetrics
and gynecology and chairman of the department
at the University of Mississippi School of Medi-
cine, has been named assistant dean of the medi-
cal school in addition to his other duties.

A University of Rochester graduate, Doctor
Thiede holds the M.D. degree from the University
of Buffalo School of Medicine and Dentistry. He
received his University of Mississippi School of
Medicine faculty appointment in 1967, prior to
which he was associate professor of obstetrics
and gynecology at the University of Rochester
School of Medicine and Dentistry.

JOURNAL MSMA

Book Reviews

Acute Renal Failure: Diagnosis and Manage-
ment. By Robert C. Muehrcke, M.D. 263 pages
with 126 illustrations. St. Louis: The C. V.
Mosby Company, 1969. $19.75.

The introduction to Acute Renal Failure by
Robert C. Muehrcke acquaints the reader with
mechanical, iatrogenic and disease states that in-
duce acute anuria. More detailed treatment of
these problems is taken up further in the book.
In addition, he also introduces diagnostic proce-
dures that are helpful in acute renal failure and
therapeutic modalities that may be useful in the
treatment of acute renal failure.

The section on intrinsic renal disease goes into
a brief historical review of terminology. The per-
plexing state of classification of interstitial nephri-
tis is not significantly changed by the author’s
discourse. The major causes of acute renal failure
are discussed and are supplemented with case his-
tories and photomicrographs of renal lesions.

The author’s most important section deals with
the etiology of acute renal failure and puts phy-
sicians on guard. The incidence of severe iatro-
genic renal disease is increasing with the increased
use of both old and new drugs. A listing of the
drugs causing acute renal failure is presented and
a diagram of a nephron showing sites of damage
is given.

The author points out that complicating medi-
cal problems alter the method of treatment of
acute renal failure. Since infection is the most
common complication, a useful listing of the ex-
cretion rate of antibiotics is given.

The portion on treatment of acute renal failure
is rather superficial but a more lengthy approach
would not be in keeping with the aim of this
book.

I have some minor disagreements with the
author, such as his recommendation to treat acute
papillary necrosis with tetracycline and Chloro-
mycetin and his sentence suggesting that all hypo-
natremic individuals with renal disease should be
corrected with hypertonic saline.

This book covers the problems of acute renal
failure in a comprehensive manner. The author
has created a clinical monograph that will be use-
ful to the practice of physicians and residents in
most specialties. The references used have in-
cluded recent publications as well as the pertinent
original publications. The reader is not bored
with the presentation of basic concepts which are
available and expected in more voluminous texts
and the cost is not out of keeping with publica-
tions of similar scope.

Karl W. Hatten, M.D.

Current Diagnosis & Treatment. By Henry
Brainerd, M.D.; Marcus A. Krupp, M.D.; Milton
J. Chatton, M.D.; and Sheldon Margen, M.D.
884 pages. Los Altos, Calif.: Lange Medical
Publications, 1970. $11.00

Medical Students are adept at finding sources
of material presented in a concise, usable man-
ner and this book has found widespread use
among them. As is stated in the Preface, it is not
intended to be used as a textbook of medicine,
but as a handy desk reference on the most widely
used and accepted techniques available for diag-
nosis and treatment. However, there are many
subjects covered which are so new that they do
not appear in the major textbooks of medicine.
For instance, Fredrickson’s classification of hyper-
lipidemias, along with diagnostic points and treat-
ment, is outlined in chart form. There are many
helpful graphs and charts scattered throughout
the book which aid in differential diagnosis.

The subjects are not indexed as thoroughly as
is desirable. The fat disorders are listed under
hyperlipidemias, not under cholesterol or triglyc-
eride. Multiple myeloma is discussed but not in-
dexed for this main discussion.

For the busy practitioner this would be a use-
ful desk reference. In addition, if more infor-
mation is needed on a particular subject, current
references from the literature are given following
each discussion.

A. Robert Dill, M.D.

NOVEMBER 1970

613

ORGANIZATION / Continued

Georgia Internists
Hold Meeting

The American College of Physicians (ACP)
will hold an annual scientific meeting for special-
ists in internal medicine and related specialties
Nov. 14 in Atlanta.

The Georgia state meeting is one of 37 state
and area scientific-educational meetings the ACP
is planning for the 1970-71 academic year. Held
throughout the United States and Canada, the
meetings help the College’s 16,000 members keep
informed of developments in the basic sciences
and in clinical medicine that affect their practices.
The College has been sponsoring these meetings
annually since 1930.

The Georgia meeting is being planned under
the direction of Dr. Tully T. Blalock, Atlanta,
ACP Governor for Georgia and assistant pro-
fessor of medicine at Emory University School of
Medicine.

Alabama Scientist
Studies Sleep

Insomnia, sleepwalking, nightmares, they’re
just three of the “sleep” problems most people
would like to banish, or at least control.

Scientists at the University of Alabama in
Birmingham are setting out to do something about
these nuisances. Their work could bring cures for
some types of mental illness and control of such
sleep-related conditions as fatigue, alertness, and
general physical and mental well being.

A scientist who is conducting extensive re-
search into sleep, Dr. G. Vernon Pegram, Jr.,
has joined a new UAB brain research program.
Dr. Pegram, most recently chief of the Bio Effects
Division at Holloman Air Force Base, New
Mexico, is executive secretary to the international
sleep research organization, the Association for
the Psychophysiological Study of Sleep. His new
appointment is in experimental psychiatry at the
UAB School of Medicine, and he will be working
in the UAB Neurosciences Program.

“Insomnia and mental illness are closely re-
lated,” said Dr. Pegram, who explained that there
is a physiological need in each man for a certain
amount of sleep. When sleep patterns are dis-
turbed, an individual's whole outlook is altered.
He may be affected both physically and mentally.

In addition, man’s physiological needs are not
just for sleep , but for specific amounts of specific
types, or stages, of sleep. It is important, says
the scientist, for each sleep stage to remain con-
stant. Dr. Pegram’s research has dealt largely
with the field of sleep-staging.

Because rhesus monkeys have sleep stages
similar to those of man, and because the brain
transmitters which produce sleep are similar in
both man and rhesus, Dr. Pegram has worked
extensively with the primates in his search for
answers to the riddle of sleep, “one of man’s basic
drives.”

Through computer technology, Dr. Pegram and
other scientists have learned to utilize the “sleep
prints” of both monkeys and people. The prints,
which represent electrical activity in the brain
during a full night’s sleep, are analyzed by the
computers, allowing scientists to accomplish in
minutes what once took them many hours of
skilled interpretation.

What are the goals of sleep researchers? Dr.
Pegram explains that this basic need, if under-
stood and controlled, may enable man to in-
crease or decrease at will the amount of sleep
he has each night, sleep better when he does go
to bed, stay more alert and active during his
waking hours, stay mentally healthy throughout
his life, and do away with such annoyances as
sleepwalking, insomnia, fitful sleep, and night-
mares.

Through research into the nature of sleep pat-
terns, more sophisticated forms of therapy may
be discovered for treatment of drug abusers.

Even good news for the seasoned traveler may
come from the research of Dr. Pegram and his
associates. When flying from time zone to time
zone, therefore “losing” or “gaining” time which
disturbs the ordinary cycles of sleep and wake-
fulness, it may take days for a traveler to “get
back to normal.” When sleep can be controlled,
the problem may never arise again. Drugs which
allow a person to “catch up” on the sleep he
has missed may be just around the corner.

Dr. Pegram, a native of Nashville, Tenn., re-
ceived his Ph.D. degree in psychology from the
University of New Mexico and his B.S. degree in
biology from the University of the South, Se-
wanee, Tenn.

Prior to his Holloman AFB appointment, Dr.
Pegram was head of the Neurosciences Program
at Holloman Aeromed. He has served in the De-
partment of Psychology, University of New Mexi-
co, and the Holloman Physiology Section. He
was a postdoctoral fellow of the National Science
Foundation, National Research Council.

614

JOURNAL MSMA

CHP Study Would Consolidate State
Agencies and Abolish Board of Health

A study report recommending sweeping reor-
ganization of state health and health-related agen-
cies has been released by the Division of Com-
prehensive Health Planning. The report and rec-
ommendations relate to a study conducted for
CHP by Peat, Marwick, Mitchell and Co., a na-
tional firm of certified public accountants and
management consultants.

Heart of the study recommendations is con-
solidation of 20 health and health-related state
agencies into a single Commission for Health Pro-
grams. Among agencies to be abolished as sep-
arate entities and combined under the new com-
mission are the State Board of Health, charity
hospitals, State Hospital Commission, Board of
Trustees of Mental Institutions, Medicaid Com-
mission, Cerebral Palsy Hospital School, Com-
mission of Hospital Care, Air and Water Pollu-
tion Control Commission, and Interagency Com-
mission on Mental Illness and Retardation.

The new commission would consist of seven
members, four of whom would be appointed by
the governor, two by the lieutenant governor, and
one by the speaker of the House of Representa-
tives. The commission would have a director and
staff.

Also consolidated would be professional li-
censure for physicians, dentists, nurses, and al-
lied professional personnel under a single multi-
discipline board with a single administrative of-
fice.

The study report lists 53 state agencies with
principal or secondary activities in health or
health services with a combined annual appro-
priation of about $78 million. The consolidation
move, approved by the Comprehensive Health
Planning office and transmitted to the legislature,
would reduce the number of state employees in-
volved and expenditures, the report contended.

The Departments of Public Welfare and Edu-
cation, both with health functions, would be un-
affected in the consolidation, as would be the

Board of Trustees of Institutions of Higher Learn-
ing under which the University Medical Center is
operated.

The study report said that $22 million is being
expended annually for purchase of health services
from the private sector. Of this $17 million is
in federal funds. This includes the Medicaid pro-
gram for the first six months of 1970. About $9.6
million are expended for totally federal fund proj-
ects, including the Tufts-Delta project, the Coun-
ty Health Improvement Program (CHIP), the
UMC Regional Medical Program, the Mound
Bayou Hospital, and various community action
agencies.

The CHP program is guided by a 40-member
advisory body of which seven key health-related
agency chief are ex officio, non-voting members.

Physicians on the 33-member voting body are
Drs. Temple Ainsworth of Jackson, Guy D.
Campbell of Jackson, Verner S. Holmes of Mc-
Comb, Edley H. Jones of Vicksburg, William
E. Lotterhos of Jackson, Gilbert R. Mason of
Biloxi, and Rhea L. Wyatt of Holly Springs.

Dr. Holmes is chairman of the advisory coun-
cil as well as representative of the Board of
Trustees of Institutions of Higher Learning.

The report stated that extensive changes in law
by the legislature will be necessary to implement
the sweeping plan, since each of the 20 agencies
to be abolished are under separate laws. It is ex-
pected that legislation will be presented to the
1970 Regular Session in January.

The new agency concept has met opposition
from some medical and legislative leaders. The
Associated Press reported that Sen. Hayden
Campbell of Jackson, chairman of the Senate
Committee on Public Health, opposes the plan.

Sen. Campbell was quoted as saying that the
plan “would abolish the State Board of Health
which we have kept out of politics.”

The Senator also said that “this plan will put

NOVEMBER 1970

615

ORGANIZATION / Continued

all our agencies into politics.”

Dr. William E. Lotterhos of Jackson, newly in-
stalled president of the American Academy of
Family Physicians, told the Journal that he op-
poses the recommendations and proposed aboli-
tion of state health-related agencies. Another
medical leader on the advisory council voiced ob-
jections to the consolidated licensure function for
professional individuals.

Association spokesmen said that the Council
on Medical Service and Board of Trustees will
study the report and recommendations prior to
the convening of the 1971 legislative session.

Also included in the recommendations is a
proposal to combine county public health de-
partments into districts with 10 regional offices
throughout the state.

The AP reported that Dr. Holmes, chairman of
the advisory council, transmitted the report to the
legislature stating that the body’s interest was not
to be critical of any program but to set up the
best possible organization to manage them.

He was quoted as saying to the legislators that
the consolidation could be achieved as recom-
mended in the report or through “some alterna^
tive which you in your wisdom and counsel feel
would better secure the desired goal.”

The news story said that the study cost $80,-
000 and covered a five-month period.

ICS Will Meet
in Las Vegas

The program for the Third Western Hemi-
sphere Congress to be held in Las Vegas, Nov.
20-24, 1970, will feature Canadian, United States,
Mexican and South American surgeons. There
will also be guests from other nations presenting
papers.

Mr. Frederick Fitzgerald, Orthopedist of Har-
ley Street, London, Prof. Francois Mattei of
France, Prof. Dr. D. Juzbasic from Yugoslavia,
and Prof. Dr. Med habil A. K. Schmauss from
East Berlin, are a few of the world wide surgeons
to be presented.

Dr. Esteban D. Rocca of Lima, Peru, will suc-
ceed Dr. Ed Compere of Chicago as president of
the International College of Surgeons Jan. 1,
1971. Dr. Lawrence W. Long of Jackson, Miss.,
will continue in the office of treasurer for two
more years, having been re-elected in Paris last
April.

UMC Announces
Faculty Changes

A number of faculty changes at the University
of Mississippi School of Medicine went into effect
in October.

Dr. Thomas M. Blake has been promoted
from associate professor of medicine to professor.
A Vanderbilt University School of Medicine grad-
uate, Dr. Blake joined the University of Missis-
sippi medical school faculty in 1955.

Promotions from assistant professor to associ-
ate professor include director of pulmonary re-
search Dr. Myra Tyler, medicine; Dr. Francis
S. Morrison, medicine; and co-director of the
MRMP demonstration stroke unit Dr. Robert R.
Smith, neurosurgery.

Dr. Michel Hersen, new associate professor of
psychiatry (psychology), holds the B.A. degree
from Queens College and the M.A. from Hofstra
University. He earned the Ph.D. from the State
University of New York at Buffalo in 1966.
Prior to his appointment. Dr. Hersen was director
of internship training at Fairfield Hill Hospital in
Newton, Connecticut.

Sister Mary Bernadette Ferrel of Aberdeen,
S. D., Miss Suzanne Robert of Montreal, Canda-
da, and Mrs. Minta Uzodinma of Jackson are
new associates in the department of obstetrics
and gynecology, in connection with the nurse-
midwifery program. All are among the program’s
first graduates.

Two new faculty members, Dr. Robert W.
Scott and Dr. Gaston R. Rodriguez, joined the
University of Mississippi School of Medicine
teaching staff in September.

Dr. Scott, psychiatry (psychology) assistant
professor, holds the B.S. degree from the Univer-
sity of Arkansas and the M.S. from Oklahoma
State University. He earned the Ph.D. degree in
1968 at the University of Houston, taking his
internship at Oklahoma University Medical Cen-
ter, where he was an instructor. Prior to his ap-
pointment, Dr. Scott was a clinical psychologist
at the Miami V. A. Hospital and psychological
consultant to the Dade County Public Schools,
Northeast District, in Florida.

A native of Lima, Peru, Dr. Rodriguez is an
instructor in medicine. He received the M.D.
degree from the University Nacional de Son Mar-
cos in Lima. He interned at St. Francis Hospital
in Pittsburgh, Pennsylvania, and did his residency
at the University Medical Center in Jackson,
where he was also a fellow and research associate.

616

JOURNAL MSMA

Richman Essay
Contest Announced

Announcement of the 1971 Alfred A. Rich-
man Essay Contest was made today by the
American College of Chest Physicians. The an-
nual contest offers undergraduate medical stu-
dents throughout the world the opportunity to
submit in open competition manuscripts on any
phase of the diagnosis and treatment of cardio-
vascular or pulmonary disease.

Research or review articles relating to the diag-
nosis or treatment of cardiovascular or pulmonary
disease are acceptable. In accord with the rules
of the contest, preceptors are at liberty to assist

the student in selecting a suitable subject and
guide him in the preparation of his essay.

Three cash prizes totaling $1,000 are award-
ed annually. The first prize will be $500; second
prize, $300 and third prize, $200. Each winner
will also receive a certificate of merit. A trophy
inscribed with the name of the winner and the
name of his school will be presented to the
winner’s school.

The winning essayist will be announced by
the judges in June, and subsequently, awards will
be presented at the Annual Meeting of the Col-
lege in October.

The official application form may be secured
by writing Essay Contest, American College of
Chest Physicians, 112 East Chestnut Street, Chi-
cago, 111. 60611, USA.

Dr. Carter Honored at Open House

University of Mississippi Medical Center faculty,
staff, other personnel and students attended a re-
ception for Dr. and Mrs. Robert E. Carter, left, on
Sept. 28, 1970. Dr. Carter resigned his post as Medi-
cal Center director and medical school dean, effective
Oct. 1, to accept an appointment as Dean of the

Basic Sciences for Medical Education at the Univer-
sity of Minnesota new Duluth campus. Dr. and Mrs.
Robert E. Blount, right, talk with the Carters at the
open house. Dr. Blount, former assistant director
and assistant dean, is currently acting director and
acting dean at the Medical Center.

NOVEMBER 1970

617

ORGANIZATION / Continued

Dr. Brumby Day Held
in Lexington

Dr. Paul B. Brumby of Lexington, president
of the Mississippi State Medical Association, was
honored with a reception and special ceremony
at the Holmes County Country Club in late Sep-
tember.

More than 400 friends, civic leaders, and as-
sociates were present to pay tribute to the physi-
cian who has practiced medicine in Holmes
County for 40 years. The Lexington Lions,
Rotary, and Business and Professional Women
clubs were in charge of arrangements.

Guests were greeted by Mr. C. M. McDaniel
and presented to the receiving line composed of
Dr. and Mrs. Brumby and their daughter and
son-in-law, Mr. and Mrs. Donald Holder of New
Orleans.

Mr. Marvin McLellan, master of ceremonies,
presented Dr. Brumby with a plaque inscribed
with the following words: “Presented to Paul B.
Brumby, M.D. in appreciation for more than
forty years of unselfish, devoted and humane
medical service to our community,” and signed
“Friends.”

The Board of Trustees of the Holmes County

Dr. J. Dan Mitchell of Jackson, right, MSMA
vice president, presents a letter of tribute from the
association to Dr. Brumby, center, as Mrs. Brumby
looks on.

Community Hospital passed a resolution express-
ing “the deep appreciation of that board and
the community at large for his years of profes-
sional and personal service.”

Mr. C. B. Read, Administrator of Holmes
County Community Hospital, read a letter from 1
the hospital Board of Trustees and employees.
The letter stated that in lieu of a gift, they had
commissioned a portrait of Dr. Brumby to be
painted and placed in the hospital.

Dr. J. Dan Mitchell of Jackson, vice president
of MSMA, read a letter of tribute from the medi-
cal association.

Mr. Alton Parker, chairman of Selective Ser-
vice Board No. 29, presented a special certificate
of appreciation for loyal and faithful service to
the nation and Selective Service System as medi-
cal advisor to the registrants since World War II.

Also representing the medical association were
Dr. A. E. Brown, president-elect and Mrs.
Brown of Columbus.

MHA Announces
Research Program

The Mississippi Heart Association has an-
nounced its 1971-72 research grants and fellow-
ships program.

The research program was instituted to aid in
the development of cardiovascular research, and
of future leaders in the broad field of cardio-
vascular function and disease. The research funds
are used to support individual investigators and
research projects.

Each year the association makes the follow-
ing research awards: (1) to the University Medi-
cal Center in support of the Love Memorial
Chair of Cardiovascular Research — no less than
$20,000; (2) to departments in Mississippi in-
stitutions of higher learning engaged in cardio-
vascular research to establish research fellow-
ships. The stipend is $6,000 plus a dependency
allowance of $500. Departments must apply each
year for continuation of fellowships; (3) to indi-
vidual investigators, grants-in-aid from $2,000 to
$4,000 to encourage support of basic and clinical
research in cardiovascular function or disease, or
in related fundamental problems. Grants are
made for one year, and the project must have the
approval of the department chairman.

Application forms may be requested at any
time from the MHA, Box 5002, Jackson, Miss.,
telephone 362-6945. Deadline for receipt of fel-
lowship and grant-in-aid applications is Nov. 23,
1970.

Awards will be announced in May, 1971, for
the year beginning July 1, 1971. The doctoral
degree is required for all categories.

618

JOURNAL MSMA

Dr. Lotterhos Discusses New AAGP Program

Dr. William E. Lotterhos (left), Jackson, family
physician and president of the American Academy
of General Practice, discusses a new pilot project
in medical communications with a physician for
HEW and the Executive Director of the Kansas
City-based Academy. Dr. Jerri Barden (center), a
representative of the Health Care Technology Di-
vision of the Health Services and Mental Health
Administration of HEW , sought the 31 ,000-member
Academy’s assistance in linking doctors’ offices with

AAOS Publishes Book
on Sports Medicine

“A Bibliography of Sports Medicine" has been
published by the American Academy of Ortho-
paedic Surgeons, Chicago.

Compiled by the Academy’s Committee on
Sports Medicine, the 96-page volume is identified
as an introduction to the interdisciplinary litera-
ture for physicians and others handling athletes
and athletic programs.

More than 1,300 article and publication refer-

a federal computer center in Valley Forge, Pa.,
through use of a touch-tone system combined with
the telephone system. Mac F. Cahal (right), chief
executive officer of the Academy, joined Dr. Lotter-
hos in working out a project whereby members of the
Academy will take part in the project providing them
instant access to drug incompatibility data. Dr. Lot-
terhos, who became president of the Academy Sep-
tember 30, serves also as chairman of the organiza-
tion’s Liaison Committee on Technology.

ences are cross-indexed from allergy to wres-
tling. The 175 index subjects include aquatics,
biomechanics, conditioning, drugs, equipment, the
knee, pain, research methods, scuba and skin
diving, sleep, warm-up, and weight.

The book was edited by Dr. Jack C. Hughston,
Columbus, Committee Chairman, and Kenneth
S. Clarke, Ph.D., former Academy Coordinator
of Continuing Education. It is available at $2.00
per copy with quantity discounts. Write Publica-
tions Committee, American Academy of Ortho-
paedic Surgeons, 430 North Michigan Avenue,
Chicago, 111. 60611.

NOVEMBER 1970

619

ORGANIZATION / Continued

Alabama Has 3 Year
M.D. Degree Program

Starting next July, Alabama’s medical students
can obtain their M.D. degrees in three years in-
stead of the traditional four.

Dr. Clifton K. Meador, dean of the School of
Medicine, University of Alabama in Birming-
ham, made the announcement.

The School of Medicine is one of several U. S.
medical schools undergoing extensive curriculum
changes in an effort to provide a more relevant
education for the modern medical student.

“Advantages of the curriculum changes are
numerous,” said Dr. T. Albert Farmer, director
of the school’s Office of Undergraduate Medical
Education.

“Now the medical student can decide a year
earlier the directions that his career will take,”
he said.

One great advantage in the new curriculum
will be the year-round use of all medical teach-
ing facilities, instead of the virtual closing down
of the school during the summer.

“The new program has tremendous recruiting
appeal for Alabama youth. Our main goal is to
train Alabamians for practice in our state.
Once he knows that he can get his medical educa-
tion in three years — a shorter period of time than
the vast majority of other medical schools — the
aspiring medical student will be encouraged to
train here,” said Dr. Farmer.

In order to get the most out of educational
facilities at the University of Alabama School of
Medicine, freshmen will attend the first five
quarters of school without a break.

“In a nation needing more and better health
manpower, we cannot afford to lose valuable
summer months during which we could be train-
ing future physicians,” Dr. Farmer said.

The remaining seven quarters of medical edu-
cation will be tailored for the individual student,
leaving room for some to hold jobs, others to take
vacations, still others to graduate in three and
one-half or four years if necessary.

“We will be oriented toward having a student
learn what he actually needs to know or be able
to do,” said Dr. Farmer. “We want our future
graduate to be more of a problem-solver, able to
identify patients’ problems and solve them as
quickly and expertly as possible.

“The crisis-oriented present system must be
supplemented by emphasis on comprehensive

care with better efforts at preventive medicine.”

The new curriculum will introduce clinical ex- |
perience to the new medical student virtually
from the first day of training.

A major reduction in formal classroom time
will allow the student to assume more responsi-
bility for his own personal learning, thereby estab-
lishing a pattern for a lifetime of learning.

“During his education, the student will have
experiences with a full range of situations similar
to those he will encounter in actual practice.

“The curriculum should provide an opportu-
nity for the student to recognize the broad social
and economic responsibilities of the medical pro-
fession as a whole,” Dr. Farmer concluded.

Dr. Blount Named
UMC Acting Director

Dr. Robert E. Blount, assistant director of the
University of Mississippi Medical Center and
assistant dean of the School of Medicine, has
been appointed acting director and acting dean
by the Board of Trustees, Institutions of Higher
Learning.

Former UMC director and School of Medicine
dean Dr. Robert E. Carter resigned his post to

accept an appoint-
ment as Dean of the
Basic Sciences Pro-
gram for Medical Ed-
ucation at the Uni-
versity of Minnesota
new Duluth campus.

Dr. Blount, who is
also medicine profes-
sor and preventive
medicine associate
professor, came to the
Mississippi institution
in 1968 from Fitz-
simons General Hos-
pital in Denver, Colo.,
where he was Commanding General.

During his U. S. Army career, Dr. Blount held
assignments across the United States, in the Far
East and in Europe. Prior to his Denver post,
he served as Commanding General of the U. S.
Army Medical Research and Development Com-
mand in the Office of the Surgeon General.

The new acting dean and acting director, a
Millsaps College graduate, earned the M.D. de-
gree at Tulane University School of Medicine
and interned at the U. S. Marine Hospital in New
Orleans. He entered active duty in 1933.

620

JOURNAL MSM A

Medical Center Hosts
Attorney General

A. F. Sumner, center , Mississippi Attorney General,
spoke to faculty and students on “Mississippi and
Minnesota” at the year’s first Student Assembly.
This lecture series, now in its second year , features
monthly speakers from various fields. School of
Medicine junior Bill Tatum of Meridian, left, chair-
man of the Student Assembly programs, and senior
Donald Blackwood of Drew, right, student body
president, greet the visiting state official.

Illinois Plans
Postgraduate Course

The Department of Otolaryngology of the Eye
and Ear Infirmary of the University of Illinois
Hospital and the Abraham Lincoln School of
Medicine of the College of Medicine, University
of Illinois at the Medical Center, will conduct
a postgraduate course in laryngology and bron-
choesophagology March 15-26, 1971.

This course is limited to 15 physicians and
will be under the direction of Dr. Paul H. Holin-
ger. It will be held largely at the Eye and Ear
Infirmary, 1855 West Taylor Street, Chicago, and
will include visits to a number of other Chicago
hospitals.

Instruction will be provided by means of animal
demonstrations and practice in bronchoscopy and
esophagoscopy, diagnostic and surgical clinics, as
well as didactic lectures.

Interested registrants will please write directly

to the Department of Otolaryngology, University
of Illinois at the Medical Center, Postoffice Box
6998, Chicago, Illinois 60680.

Ole Miss Publishes
Marihuana Index

The world’s scientific literature on “pot” has
been indexed in a 200-page bibliography pub-
lished this week by the University of Mississippi.

The “Annotated Bibliography of Marijuana
1964-1969” is being issued by the School of
Pharmacy’s Research Institute of Pharmaceuti-
cal Sciences under a contract with the National
Institute of Mental Health. The publication was
edited by Dr. Coy W. Waller, director of the Re-
search Institute, and staff members Dr. Hugh
D. Bryan, Jacqueline J. Denny and Lois P.
Schiff.

The index to international scientific literature
includes information on marihuana found in jour-
nals in the free world as well as in publications
behind the iron curtain. The bibliography includes
references to some 800 books, magazines, jour-
nals, and articles relating to Cannabis Sativa L.,
the technical name for “pot.”

Dr. Waller said the bibliography was issued
because of a great amount of scientific literature
published on marihuana in recent years.

“The last such publication was published in
1965 by the United Nations Commission on
Narcotic Drugs and included 1,860 references.
Considerable progress has been made in the last
six years on the chemistry of the constituents in
marihuana and an updating of the bibliography of
scientific literature is timely,” Dr. Waller said.

“The cannabis literature during the years 1964-
69 contains many reports on the chemistry of the
plant constituents, synthesis of the tethrahydro-
cannabinols and cannabinoids — the active in-
gredients— and the use of new analytical tools to
identify and confirm the major components of
cannabis.”

Dr. Waller said advances in the chemical
knowledge of marihuana appear to precede a new
wave of study of the biological aspects of the
drug. “It is predicted that during the next five
years, major contributions to the knowledge of
the pharmacology, toxicology, teratology and
medicinal use of cannabinoid will be published,”
he said.

Dr. Waller, consultant to the National Institute
of Mental Health on its national marihuana re-
search program, said the bibliography would
be made available to scientists.

NOVEMBER 1970

621

ORGANIZATION / Continued

Chicago Society
Sets Two PG Courses

The Chicago Medical Society will sponsor two
postgraduate courses in November, 1970. A
course in internal medicine will be held Nov.
9-13, and a course in obstetrics and gynecology
will be featured Nov. 16-20.

The courses will be held in the Knickerbocker
Hotel, 163 East Walton, Chicago.

Registration is limited. The registration fee for
each course is $150.00 which includes luncheon
tickets, refreshments and a booklet summarizing
each lecture. A limited number of resident phy-
sicians will be accommodated at a reduced fee.

Dr. Peter J. Talson is chairman of the internal
medical course, and Dr. Charles P. McCartney
is chairman of the course on obstetrics and
gynecology.

The program is acceptable for 3 2 Vi elective
hours by the American Academy of General
Practice.

For further information and applications, write
the Chicago Medical Society, 310 S. Michigan
Avenue, Chicago, 111. 60604.

APA Salutes SK&F
Remotivation Project

The American Psychiatric Association has pre-
sented a special award to Smith Kline & French
Faboratories for its involvement and contribu-
tions to the “Remotivation” project, a highly suc-
cessful therapeutic program used in mental hos-
pitals for the past 14 years.

Mr. Charles F. Bolling, a vice president in
SK&F’s Pharmaceutical Division, accepted the
award from Dr. Robert S. Garber, APA Presi-
dent, at the opening session of the APA’s 22nd
annual Institute on Hospital and Community
Psychiatry recently held at the Sheraton Hotel.

Dr. Garber has been associated with the “Re-
motivation” program for many years.

Remotivation is a therapeutic technique used
by the psychiatric aide with his own patients, but
under the supervision of a professional nurse.
It augments other therapy — not replaces it.

The program consists of a series of patient
meetings held once or twice a week under the
leadership of the aide who initiates a discussion
that is purely objective in nature. The sessions
give even the most regressed patient the oppor-

tunity of enjoying something with other people.

Remotivation originated at the Philadelphia
State Hospital in 1956. Increased interest led to
the formation of the Remotivation Advisory Com-
mittee of the APA Mental Hospital Service. The
committee worked with SK&F’s Mental Health
Education Unit in establishing programs through-
out the country.

From 1956 to 1960, SK&F, working with the
APA, planned, coordinated and paid for classes,
seminars and demonstrations that taught the tech-
nique to thousands of nurses and aides. SK&F
continued its financial support after the APA as-
sumed full administrative control of the program
in 1960.

The program has been recently decentralized
with 17 hospitals around the country designated
as regional training centers by the APA. It is
self-sustaining and requires no additional support
from SK&F, the Philadelphia, Pa., manufacturer
of prescription medicines and other health-re-
lated products.

Dr. Leathers’ Portrait
Donated to UMC

The University of Mississippi Medical Center has
received a portrait of the late Dr. Waller S. Leathers,
first dean of the University of Mississippi School of
Medicine who later served with distinction as dean
of the Vanderbilt University medical school. Dr. and
Mrs. James E. Ridgeway of Tampa, Fla., at right,
made the presentation. Mrs. Ridgeway is the artist.
Her husband, formerly of Vanderbilt Clinic, College
of Physicians and Surgeons, Columbia University,
was a student at the Ole Miss two-year medical
school on the Oxford campus when Dr. Leathers was
dean. Dr. David B. Wilson, left, University Medical
Center assistant director for health planning, accepts
the painting on behalf of the University.

622

JOURNAL MSMA

Family Doctor Group
Takes New Name

The nation's second largest medical group has
voted to change its name of 23 years. The Ameri-
can Academy of General Practice, national as-
sociation of family physicians, now will become
known as the American Academy of Family
Physicians.

The action, which will take a year to develop
fully, was taken by the Academy’s Congress of

Delegates in the final
session of the group’s
annual meeting at the
Fairmont Hotel. It
immediately preceded
election of Dr. J. Je-
rome Wildgen, Kali-
spell, Mont., as presi-
dent-elect. Dr. Wild-
gen will become presi-
dent a year from now
at the organization’s
meeting in Miami
Beach.

Dr. William E. Lot-
terhos, Jackson, Miss.,
became president of
the group in special inaugural ceremonies.

According to Mac F. Cahal, executive director,
the change of the name was an important step in
the continuing move to revitalize the nation’s pri-
mary health care forces.

“This truly is a significant thing because it
shows that doctors everywhere, including our
members, are beginning to be comfortable with
the concept of family practice, the new primary-
care specialty that is obviously beginning to take
hold,” Cahal said. “We’ve tried to do this a num-
ber of times before but only now, when the spe-
cialty has become a reality and the first examina-
tions given, has this become possible.”

Cahal said the new name more accurately re-
flects what the organization represents. He added,
however, that it will not become official until the
next meeting of the Congress (normally, the fall
of 1971) because it requires a change in the
constitution and 90 days notice to delegates. He
explained that the organization’s Board of Di-
rectors had been empowered by the Congress
of Delegates to “utilize the new name in the
interim as it sees fit,” though, so that the organiza-
tion could proceed to use the new name with
due speed.

In addition to Dr. Wildgen. these other officers

and directors were named:

Dr. Norman Coulter, Orlando, Fla., vice presi-
dent, and Drs. Robert E. Heerens, Rockford,
111.; Herbert A. Holden, San Leandro, Calif., and
Thomas L. Lucas, Alexandria, Va. The directors
will serve 3-year terms.

Drs. James G. Price, Brush, Colo., and Stan-
ley A. Boyd, Eugene, Ore., were re-elected speak-
er and vice speaker respectively of the Congress
of Delegates.

Wyeth Films Win
Festival Awards

Two films produced by Wyeth Laboratories
received awards at the 12th annual American
Film Festival, held recently in New York City.
The Festival, held under the auspices of the Edu-
cational Film Library Association, is the major
showcase each year for over 400 films and film-
strips selected from over 1,000 entries.

In the category designated “Health for General
Audience,” Wyeth’s film titled “Happy Family
Planning’ won the blue ribbon (first place in
category). Another Wyeth film, “Case In Point,”
won the red ribbon (second place) in the “Voca-
tional Guidance” category.

“Happy Family Planning” is an eight-minute
animated, color film with music, available in
either 16-mm. or 8-mm. The film, using graphic
devices and no dialogue, reviews various contra-
ceptive methods which are identified in five lan-
guages: English, French, Spanish, Arabic and
Chinese. “Happy Family Planning” is designed
for showing to lay groups, especially hospitalized
women in the immediate postpartum period. It
also can serve as a valuable educational aid in
clinics, physicians’ offices and at health meetings.

Prints of “Happy Family Planning” are avail-
able on loan through Wyeth representatives or
the Wyeth Film Library, P. O. Box 8299, Phila-
delphia, Pa. 19101. Also, prints can be purchased
at cost through Planned Parenthood Federation,
515 Madison Avenue, New York, N. Y. 10022.

“Case In Point” outlines precautions by which
the medical assistant and her physician-employer
can help protect themselves from lawsuits. Using
a documentary approach, “Case In Point” de-
picts various professional activities of the medical
assistant, and dramatizes the importance of ob-
serving fundamental safeguards in each area. The
film, which is 16-mm., color, and runs 25 min-
utes, is available for showing to physicians and
to chapters of the American Association of Medi-
cal Assistants.

Dr. Lotterhos

NOVEMBER 1970

623

ORGANIZATION / Continued

UMC Offers Nurses
Master Degree

The Board of Trustees, Institutions of Higher
Learning, has approved the state’s first master of
nursing degree program, to be offered at the Uni-
versity of Mississippi School of Nursing this year.

Program director will be Dr. Faustena Blaisdell,
who was formerly nursing professor and head of
the masters program at the University of North
Carolina at Chapel Hill. She holds B.S., N.Ed.
and Ed.D. degrees from Teachers College, Co-
lumbia University.

The new course of study was developed in di-
rect response to the demands of the state’s nurs-
ing schools for masters-level teachers and the
needs of Mississippi hospitals for equally quali-
fied nurse supervisors, according to Dean Chris-
tine L. Oglevee.

In 1970 the Mississippi State Legislature in-
creased the nursing school’s appropriation to fund
the additional curriculum load. The masters pro-
gram is largely the result of efforts by the Mis-
sissippi Nurses' Association, Mississippi State
Medical Association, Mississippi Hospital As-
sociation, junior colleges and other professional
organizations.

Plans are underway for specialization in ma-
ternal-infant care or medical-surgical nursing.

Dr. Wong Appointed
NEI Clinical Director

The appointment of Dr. Vernon G. Wong as
Clinical Director of the National Eye Institute
has been announced by Dr. Carl Kupfer, Institute
Director. The Institute is the primary Federal
organization for the support of research aimed at
improved diagnosis, prevention, and treatment of
visual disorders.

As Clinical Director, Dr. Wong is responsible
for continuous review and supervision of NEI re-
search involving patients and normal volunteers,
including overseeing the maintenance of quality
standards by physicians and nurses and the pro-
priety of patient care.

Dr. Wong has been with NEI’s Ophthalmology
Branch since 1962 when it was part of what is
now the National Institute of Neurological Dis-
eases and Stroke. Beginning as a Clinical As-
sociate, Dr. Wong advanced to the position of

Associate Ophthalmologist and Senior Investiga-
tor by 1967.

At NIH, Dr. Wong has worked in collabora-
tion with scientists of various Institutes. Among
his accomplishments has been the introduction of
immunosuppressive drugs in ophthalmology, dem-
onstrating that a number of refractory conditions
of the eye, including corneal graft rejection,
could be significantly improved by these agents.
Dr. Wong also helped develop a simple method
for diagnosing the inherited metabolic disorder
cystinosis by assaying biopsies of conjunctiva,
eliminating the need for the more difficult and
time-consuming methods previously used.

In addition to his duties as Clinical Director,
Dr. Wong will continue his current research in
uveitis and conjunctival and corneal diseases.

Medical Aspects of
Sports Meet Set

The 12th National Conference on the Medical
Aspects of Sports, sponsored by the American
Medical Association under the auspices of its
Committee on the Medical Aspects of Sports, will
be held in Boston at the Sheraton-Boston Hotel
on Nov. 29, 1970. The Conference is held an-
nually in conjunction with and on the first day
of the Clinical Convention of the American Medi-
cal Association.

As was true of the previous 11 Conferences,
the 12th will cover a wide range of subjects of
interest to those serving school and college ath-
letic programs. Included will be forums and dis-
cussion sections relating to research in sports,
aquatic sports, football rules and injuries, psy-
chology in sports, girls in sports, and emergency
and public health aspects of sports.

At the Conference Luncheon, Dr. Francis D.
Moore, Moseley Professor of Surgery, Harvard
Medical School; Surgeon-in-Chief, Peter Bent
Bingham Hospital, Boston; and eminent deep-
water skipper will discuss the topic “Sailing
Into Trouble.” At the evening session, dem-
onstrations on preventive and therapeutic taping,
and musculo-skeletal aspects of pre-participation
examination will be staged.

The Conference is open to key non-medical
athletic personnel as well as interested physicians.
Those who would like further information con-
cerning the Conference should address the Com-
mittee on the Medical Aspects of Sports, Ameri-
can Medical Association, 535 North Dearborn
Street, Chicago, Illinois 60610.

624

JOURNAL MSM A

MPAC

AMPAC

give you IMPACT, doctor!

But make it a mutual impact, doctor, because your PAC
needs you and you need your PAC. Both AMPAC and
each of the 50 state PAC’s are voluntary, nonprofit, un-
incorporated, autonomous groups whose members are
physicians, their wives, and others in allied professions.
Every group is bipartisan, bound by no party label. The
voting record, platform, and program of a candidate —
not his party — is what the PAC considers.

The basic purpose is twofold: To educate in political
affairs and to provide a means through which the physi-
cian-citizen can effectively make his voice heard in the po-
litical arena. MPAC is medically oriented and medically
directed by a 10 member board consisting of nine physi-
cians and a Woman’s Auxiliary representative.

With the elections behind, MPAC is looking ahead to
1971 when there will be a job to do. Make your voice
count by sending your dues today, $10 for MPAC and
$10 for AMPAC. Better send dues for your wife, too.

MISSISSIPPI MEDICAL
POLITICAL ACTION
COMMITTEE

NOVEMBER 1970

625

ORGANIZATION / Continued

Master of Public Health
Programs Announced

The Division of Maternal and Child Health of
the University of California School of Public
Health at Berkeley announces postgraduate pro-
grams leading to the degree of Master of Public
Health. These programs are for pediatricians,
obstetricians, and other physicians interested in
receiving training in the field of Maternal and
Child Health. Fellowship support is available, in-
cluding basic support for the trainee, and allow-
ance for dependents, tuition and fees.

Program areas now available include nine-
month programs in maternal and child health,
health of school-age children, and maternal health
and family planning. A 21-month program in
care of handicapped children, perinatology, and
comprehensive care is available. There are also
three-year career development programs in pedi-
atrics and obstetrics which combine public health
and residency training. Fellowships are available
for these programs also.

Applications are now being accepted for the
group entering September 1971. For information,
write to Dr. Helen M. Wallace, School of Public
Health, University of California, Berkeley, Calif.
94720.

NHLI Establishes
Research Centers

The National Heart and Lung Institute (NHLI )
has announced its intent to establish, on a com-
petitive basis, a limited number of specialized
research centers devoted to the solution of speci-
fic problems identified by the Institute as of high
priority, and in one of the following disease areas:
arteriosclerosis, thrombosis, pulmonary disease,
and hypertension. The objective of the program
is to focus resources, facilities and manpower
on particular problems and to expedite the de-
velopment and application of new knowledge
essential for improved diagnosis, treatment, and
prevention of these diseases.

The support mechanism for the centers will be
the grant-in-aid, but it will differ from other re-
search grants both in its goal orientation and in
the degree of participation by the National Heart
and Lung Institute. In this sense, the award of a
Center grant will connote a special relationship

between the NHLI and the grantee institution.

The deadline for receipt of applications is Jan.
1, 1971, and applicants may expect to be ad-
vised of the action on their proposals about June
1971.

The National Heart and Lung Institute is
planning to hold an orientation meeting concern-
ing the Specialized Research Center Program in
Washington, D. C., on Oct. 5, 1970.

Copies of a detailed Program Announcement
describing the NHLI Specialized Centers of Re-
search, and information concerning the orientation
meeting, may be obtained by writing to Dr.
Jerome G. Green, Associate Director for Extra-
mural Research and Training, National Heart
and Lung Institute, Bethesda, Md. 20014.

Arteriosclerosis Research

Group Meets

A new task force has met at the National In-
stitutes of Health to plan for a 10-year research
assault against arteriosclerosis — the hardening of
the arteries that leads to heart attacks and other
troubles. The 13-member group, led by Dr. Elliot
V. Newman of the Vanderbilt University School
of Medicine, was heard by Dr. Theodore Cooper,
director of the National Heart and Lung Institute.

Arteriosclerosis is a factor in the great majority
of the more than 1 million cardiovascular-disease
deaths that occur each year in the United States.
It disables hundreds of thousands more. The eco-
nomic toll runs to nearly $25 billion annually.

This disease is characterized by the gradual
narrowing — and sometimes closure — of arteries
by fatty materials and other substances in the
blood. When arteriosclerosis attacks the arteries
that nourish the heart muscle, it is called
coronary heart disease; when blood vessels to
the brain are the main target, it is called cerebro-
vascular disease; and when it threatens the blood
supply of the arms and legs, it is called peripheral
vascular disease.

In planning NHLI’s attack on this urgent
problem, the Task Force on Arteriosclerosis will
draw on the expertise of special panels, each com-
posed of specialists in fields such as cardiology,
lipid metabolism, hormone metabolism, instru-
mentation, hematology, cardiovascular physiology
and aging.

The final report of the task force is scheduled
to be submitted to NHLI in June, 1971.
It will have an important bearing on future pro-
grams by the Institute and its advisory bodies.

626

JOURNAL MSM A

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Index to Advertisers

AMPAC, MPAC 625

Arch Laboratories 627

Beckton, Dickinson and Company 612A, 612B

Breon Laboratories 8

Burroughs-Wellcome & Co. 10A

Campbell Soup Company 596A

Hill Crest Hospital 6

Hynson, Westcott & Dunning, Inc 3

Kay Surgical 627

Lederle Laboratories second cover, 4, 15

Leonard Wright Sanatorium 10

Eli Lilly and Company front cover, 18

Medicenters of America, Inc 12

The Wm. S. Merrell Company 7

The National Drug Company 604A, 604B, 616A, 616B

William P. Poythress and Co., Inc 10B

A. H. Robins Company 14, 14A, 620A, 620B

Roche Laboratories 14B, 14C, 14D, 16, 17, fourth cover

G. D. Searle Company 596B, 596C

Stuart Pharmaceuticals 586, 587, 596D

Thomas Yates and Company third cover

NOVEMBER 1970

627

Television critic Cleveland Amory, self-styled expert on labora-
t or y animals and anti vi vi s e c t i onls t extraordinary, told a House
of Representatives subcommittee that dolphins cannot be anesthe-
tized, But American Veterinary Medical Association reports that
halo thane works well on dolphins and marine animals in general.
Amory, dour critic who pans almost everything, supports proposals
to make use of lab animals much more restrictive.

A nsurgical knowledge self-assessment program" will be inaugurated
by the American dollege of Surgeons in late 1971. Designed for
those who have practiced surgery for 10 or more years, the self-
assessment consists of a home examination with bibliographies ac-
companying each question so that examinee surgeon may use referenc;
in answering. College says that no time limit is placed on pre-
paring answers to be graded confidentially by a computer center.

The American Academy of Pediatrics made a strong case against lead
based paint and has called on the Congress to make use of the mate:
al illegal in painting residential housing. Testimony was presenti
before senate committee considering H.R. 17260. the Lead-Based Pai
Elimination Act of 1970* AAP witnesses shook up committee by stati
that there is more brain damage in New York children from lead pai
than there was from measles before immunization program.

Married to the same spouse for 130 years? A definite possibility i
the future, says Dr. C. W. Hall, chief of artificial organs progra
of Southwest Research Institute of San Antonio. Dr. Hall foresees
human life span of 175 years with ersatz transplants but wonders i
it won*t cause marital problems. He also concedes that century an
a half lifetime will play havoc with life insurance actuarial tabl*
and health insurance experience.

The flap over microwave oven dangers goes on with AMA asserting tki
as many as a third of the 60,000 now in use have excessive mi crows (
leakage. The oven which bakes a cake in two minutes can emit heal
producing waves capable of causing cataracts and deep tissue bums
General Electric,” a major manufacturer of the ovens , called, in the
Bureau of Radiological Health to survey and test GE models which
were found to be safe and without leakage.

Volume XI
Number 12

December 1970

• EDITOR

William M. Dabney, M.D.

• ASSOCIATE EDITORS
George H. Martin, M.D.
Thomas W. Wesson, M.D.

• MANAGING EDITOR
Rowland B. Kennedy

• EDITORIAL ASSISTANT
Nola Gibson

• PUBLICATIONS COMMITTEE
Lawrence W. Long, M.D.

Chairman

Frank L. Butler, Jr., M.D.
William E. Lotterhos, M.D.
and the editors

• THE ASSOCIATION
Paul B. Brumby, M.D.

President

Arthur E. Brown, M.D.

President-Elect
Raymond S. Martin, M.D.

Secretary-T reasurer
William E. Lotterhos, M.D.
Speaker

John B. Howell, Jr., M.D.

Vice Speaker
Rowland B. Kennedy
Executive Secretary
H. Cody Harrell

Assistant Executive Secretary
James F. McPherson, II
Executive Assistant

CONTENTS

ORIGINAL PAPERS

Surgery of the Thymus

The Significance of
Analytical Toxicology in
the Treatment of Poisoning

Use of Artificial Kidney
in Cases of Poisoning

629 Philip E. Bernatz,
M.D.

636 Arthur S. Hume,
Ph.D., and John D.
Bower, M.D.

639 John D. Bower, M.D.,
and Arthur S. Hume,
Ph.D.

SPECIAL ARTICLE

Radiologic Seminar CII
Paget’s Disease

644 T. Scott McCay,
M.D.

EDITORIALS

The Four Faces of National
Health Insurance

647 Great Health Debate

The Growing Role of the
Joint Commission
The Doctor Has Everything,
Except Time
Hijacking and Health
Insurance
Can He Do the Job?
Then Hire Him!

650 Improving Care Quality

651 Too Much for Too Few

651 Covered in Cuba

652 Ability Counts

The Journal of the Mississippi State
Medical Association is owned and pub-
lished by the Mississippi State Medical
Association, founded 1856. Editorial, ex-
ecutive, and business offices, 735 Riverside
Drive, Jackson, Mississippi 39216; office
of publication, 1201-5 Bluff Street, Fulton,
Missouri 65251. Subscription rate, $7.50
per annum; $1 per copy, as available. Ad-
vertising rates furnished on request.
Second-class postage paid at the post office
at Fulton, Missouri.

THIS MONTH

The President Speaking 646 ‘LPN’s Fight Drug

Abuse’

Medical Organization 657 MSMA Membership

Opened to UMC
Upperclassmen

Copyright 1970, Mississippi State Medical Association

6

THE JOURNAL FOR DECEMBER 1970

AAP Makes Health
Care Recommendations

The American Academy of Pediatrics has
called for formation of a National Advisory
Council on Children which would be responsi-
ble to the President of the United States. The
Academy also called for the creation of a vol-
untary multidisciplinary national health service
corps, and a national health insurance program
to insure comprehensive coverage for all chil-
dren.

These were among the recommendations
made by the AAP in a special study on the de-
livery of health care to children, the recom-
mendations of which were presented at the
opening session of the Academy’s annual meet-
ing in San Francisco’s Civic Auditorium. The
study will be published in its entirety sometime
in 1971.

The Academy is the Pan-American association
of physicians certified in the care of infants,
children and adolescents. It has more than 11,-
500 members in the U. S., Canada, and Latin
America.

The AAP study emphasized that because of
the importance of children to society, health
programs for children require a higher degree
of priority. To accomplish this, the AAP recom-
mended the creation of a National Advisory
Council on Children, and the establishment of
an Office of Deputy Assistant Secretary for Chil-
dren and Youth in the Department of Health,
Education and Welfare.

The Academy indicated that the information
collected in the study “amply demonstrates that
the American health care delivery system for
children is presently lacking adequate numbers
of professional persons who are available, ac-
cessible, and acceptable to those in need of
care.”

The report therefore called for an expansion
in the supply of physicians to eliminate these
shortcomings through an increase in enrollment
in medical schools; an increase in scholarships,
loans and other methods of tuition financing
for medical schools; expanded and well-funded
residency programs for the training of primary
care physicians, and adequate funding for med-
ical schools “to permit them to maintain quality
teaching of large numbers of students as well

HOSPITAL

Hill Cresi Foundation , Inc.

7000 5TH AVENUE SOUTH
Box 2896,

Birmingham, Alabama 3521 2

Phone: 205-836-7201

A patient centered
non-profit hospital for
intensive treatment of
nervous disorders . . .

Hill Crest Hospital was estab-
lished in 1925 as Hill Crest
Sanitarium to provide private
psychiatric treatment of ner-
vous or mental disorders. Indi-
vidual patient care has been
the theme during its 45 years
of service.

Both male and female pa-

tients are accepted and depart-
mentalized care is provided ac-
cording to sex and the degree
of illness.

In addition to the psychiatric
staff, consultants are available
in all medical specialities.

MEDICAL DIRECTOR:

James K. Ward, M.D., F.A.P.A.

CLINICAL DIRECTOR:

Hardin M. Ritchey, M.D., F.A.P.A.

HILL CREST is a member of:

AMERICAN HOSPITAL ASSOCIATION . . .
. . . NATIONAL ASSOCIATION OF PR!-
VATE PSYCHIATRIC HOSPITALS . . .
ALABAMA HOSPITAL ASSOCIATION . . .
BIRMINGHAM REGIONAL HOSPITAL
COUNCIL.

Hill Crest is fully accredited by the Joint
Commission on Accreditation of Hospitals
and is also approved for Medicare pa-
tients.

9M C/iest

HOSPITAL

BIRMINGHAM, ALABAMA

MISSISSIPPI STATE MEDICAL ASSOCIATION

7

as to continue their needed research and service
functions.”

The AAP further called for the institution
throughout the country of training programs
for pediatric nurse associates, pediatric office as-
sistants, and pediatric aides to improve the
quantity and effectiveness of care provided to
children.

The AAP urged that incentives be made avail-
able to stimulate the “better distribution of
health professionals to areas of greatest need so
as to provide medical care of high quality to the
entire spectrum of the population.”

The study also called for the creation of a
voluntary multidisciplinary national health ser-
vice corps to provide the opportunity for all
types of health personnel to join such a corps
in an effort to deliver health care services to
those areas not now receiving such services.

In examining the methods of financing the
delivery of health care to children, the Acade-
my report pointed out that child health care is
far too expensive for millions of families, and

that voluntary health insurance is beyond the fi-
nancial capabilities of many families. “With
few exceptions, prepaid health insurance poli-
cies give very inadequate coverage of child
health care services,” the study revealed. The
Academy therefore called for the development
of a national health insurance program “that
will insure comprehensive coverage for all chil-
dren.”

The Academy report also examined the health
care of special groups of children. The AAP
pointed out that large numbers of children, par-
ticularly those living in remote rural areas or in
urban ghettos, can only obtain health care for
acute and serious illnesses, “and even this is
done with difficulty.”

In other recommendations, the Academy
called for the recognition that dental services
are an integral part of child health care. The
AAP further urged that ongoing surveys of
health needs, as seen by families, be undertak-
en as an essential step in planning the restruc-
turing of health care systems.

8

THE JOURNAL FOR DECEMBER 1970

LOOK IN
THE BOOK

When you have problems filling out claim forms, you’ll
find the Blue Shield Physician’s Manual a helpful reference.
The “blue book’’ also explains the function of Blue Cross
- Blue Shield as a voluntary, non-profit prepayment health
care plan. Representatives, who visit physicians’ offices reg-
ularly with up-to-date information on Blue Cross - Blue
Shield, will be glad to answer any questions you may have
which are not discussed in the Manual.

BLUEC-CROSS. BLUElSHIELD.

Mississippi Hospital & Medical Service
530 E. Woodrow Wilson / P. O. Box 1043 / Jackson, Mississippi 39205 / 366-1422

December 1970

ar Doctor:

der's raiders have hit American medicine, calling for a National
dical Board with full authority over delivery of services in
e consumer crusader also called for uniform national standards
perfomance for physicians, standardized medical records on com-
ters , and a system to control and limit entrance into and contin-
tion of medical practice.

The 230-page report was prepared by two law students,
a medical student, an attorney, ana a former FDA M.D.

Unlike other Ralph leader projects, the medical report
generated little public interest. AMA President Walter
Bomemeier issued perfunctory statement in response.

i tain's new conservative government is putting crunch on welfare
ate, taking away some of the National Health Service benefits,
escription co-pay is up 60 per cent, and price of eyeglasses has
en raised. Most drastic cutback is requirement for public to pay
If of dental care costs against former deductible of only $3*60
r course of treatment. Move is seen as pro-free enterprise.

e California legislature enacted Gov. Regan's program to place
1 health and medical activities under state department of health,
position to move, however, made the governor promise to delay im-
ementation of program two years. In Mississippi, current try is
derway to abolish State Board of Health and 20 other health-re-
ted offices, creating new single state agency.

ssissippi ranks first among eight southeastern states in accept-
ce of Medicare assignments by physicians! Rate for state is now
A per cent, meaning that less than l5 per cent of Mississippi
D. 's bill Medicare patients directly. Average among eight states
region is 68 per cent assignments. Florida physicians have low
te, taking assignment on only 49 per cent of Medicare claims.

out 600 MSMA members have established current year income tax
duct ions by paying 1971 dues. New billing statement, sent six
eks ago , permits members to pay all dues in one check with docu-
ntation of transaction. State association reports local society
es back to home unit secretary. Members are asked to respond to
llings now for improved administration and tax records.

Sincerely,

Rowland B. Kennedy
Executive Secretary

MISSISSIPPI STATE MEDICAL ASSOCIATION

1 1

Tulane Plans
Therapeutics Symposium

Dr. Arthur C. DeGraff, professor of medicine
and cardiology. New York University, and Dr.
William J. Grace, chief of medicine at St. Vin-
cent’s Hospital, New York City, and professor
of clinical medicine, New York University, will
participate in a one-and-a-half-day therapeutics
session at Tulane University School of Medicine
on Jan. 8-9, 1971.

Co-directors of this brief refresher symposi-
um will be Dr. George E. Burch, chairman, de-
partment of medicine and professor of medi-
cine, together with Dr. F. Gilbert McMahon,
head of therapeutics and professor of medicine
at Tulane. Several other members of the de-
partment of medicine at Tulane will also par-
ticipate in this meeting.

The meeting is aimed at clinicians and is in-
tended to be a refresher course. The manage-
ment of some common cardiovascular problems,
the proper use of digitalis, management of
acute myocardial infarction, hypertension, ar-
rhythmias, and hyperlipidemia will be among
the problems discussed. Tuition is free.

Albany Medical College
Announces Seminar Cruise

The Department of Postgraduate Medicine
of Albany Medical College announces that res-
ervations are now being accepted for the 12th
Postgraduate Medical Seminar Cruise Jan. 5-20,
1971.

The trip includes a 15-day cruise from New
York aboard the luxurious and distinguished
ship “Gripsholm” of the Swedish American
Line.

Ports of call include San Juan, Dominica, St.
Vincent, Trinidad, Barbados, Martinique, and
St. Thomas.

Faculty of the Albany Medical College will
present a comprehensive shipboard postgradu-
ate program, covering subjects in internal med-
icine, cardiology, oncology, psychiatry, surgery,
and obstetrics and gynecology.

Request has been made for continuation
study credit by the American Academy of Gen-
eral Practice.

For information write to: Dr. Girard J.

Craft, Department of Postgraduate Medicine,
Albany Medical College, Albany, New York
12208.

LEONARD WRIGHT SANATORIUM

BYHALIA, MISSISSIPPI 3861 1 TELEPHONE A/C 601, 838-2162

LEONARD D. WRIGHT, SR., B.S., M.D., PSYCHIATRY

• Established in 1948. Specializing in the treatment of ALCO-
HOLISM and DRUG ADDICTIONS with a capacity limited
to insure individual treatment. Only voluntary admissions ac-
cepted.

• Located 25 miles S. E. of Memphis-Highway 78 on 20 acres
of beautifully landscaped grounds sufficiently removed to
provide restful surroundings.

• The Sanatorium is approved by The Commission on Hospital
Care in the State of Mississippi.

1 2

THE JOURNAL FOR DECEMBER 1970

Cryosurgery Society

To Meet

The Society for Cryosurgery will hold its reg-
ular meeting March 1-6, 1971, at the Diplomat
Hotel and Country Club in Hollywood, Fla. Dr.
Richard Lillehei, Department of Surgery, Uni-
versity of Minnesota, will preside.

Section topics and leaders are: Cryosurgery
for Cancer and General Surgery, Dr. William
Cahan, Cancer Memorial Hospital, New York;
Urology, Dr. Maurice Gonder, Millard Fillmore
Hospital, Buffalo; Dermatology, Dr. Douglas
Torre, Columbia-Presbyterian Hospital, New
York; Gynecology, Dr. Frank Paloucek, Cancer
Prevention Center, Chicago; Otolaryngology,
Dr. Daniel Miller, Massachusetts Eye and Ear
Infirmary, Boston.

Because of great demand for a longer session,
the ophthalmology section will hold a three-day
meeting March 4-6. Included among the speak-
ers are: Dr. Claes Dohlman, Retina Foundation,
Boston; Dr. Harvey Lincoff, Cornell University,

New York; Dr. Harold Scheie, University of l*
Pennsylvania, Philadelphia; Dr. Charles Schep-
ens, Retina Foundation and Harvard Universi-
ty, Boston; and Dr. Saul Sugar, Wayne State
University, Detroit.

For further information, write: Mary True-
blood, Secretary, Society for Cryosurgery, 30 N.
Michigan Avenue, Chicago, 111. 60602.

New Historical
Journal Published

History of Medicine, a new journal for phy-
sicians interested in medicine and the arts, has
made its debut in the United Kingdom.

The journal is published quarterly and con-
tains biographical, historical and literary fea-
tures by lay and medical authorities.

Subscription price is $6.00 annually including
postage.

Dr. Harold Maxwell is editor and the journal
is published at History of Medicine, Ltd., 78
Queen Victoria Street, London E.C. 4.

Announcing the Thirty-Fourth Annual Meeting of
THE NEW ORLEANS GRADUATE MEDIEAL ASSEMBLY

Conference Headquarters— -The Roosevelt Hotel— March 8, 9, 10, 11, 1971

GUEST SPEAKERS

Chas. Ronald Stephen, M.D., Dallas, Tex.
Anesthesiology

Alejandro F. Castro, M.D., Washington, D.C.

Colon and Rectal Surgery
Alexander A. Fisher, M.D., Woodside, L.I., N.Y.
Dermatology

Thomas P. Almy, M.D., Hanover, N.H.
Gastroenterology

Jack H. Hall, M.D., Indianapolis, Ind.

General Practice

Denis Cavanagh, M.D., St. Louis, Mo.
Gynecology

John T. Galambos, M.D., Atlanta, Ga.

Internal Medicine
Roger F. Palmer, M.D., Miami, Fla.

Internal Medicine

Nathan S. Schlezinger, M.D., Philadelphia, Pa.
Neurology

Ernest W. Page, M.D., San Francisco, Calif.
Obstetrics

Henry F. Allen, M.D., Boston. Mass.
Ophthalmology

Phillip L. Dav, M.D., San Antonio, Tex.

Orthopedic Surgery
Edley H. Jones, M.D., Vicksburg, Miss.
Otolaryngology

John A. Shively, M.D., Columbia, Mo.
Pathology

Max D. Cooper, M.D., Birmingham, Ala.
Pediatrics

William B. Seaman, M.D.. New York, N.Y.
Radiology

Robert S. Litwak, M.D., New York, N.Y.
Surgery

Edward R. Woodward. M.D., Gainesville, Fla.
Surgery

James F. Glenn, M.D., Durham, N.C.
Urology

Lectures, clinicopathologic conference, round-table luncheons, medical motion pictures, technical exhibits, and en-
tertainment for visiting wives.

(All-inclusive registration fee — S35.00)

For information concerning the AssemSdy meeting write Secretary,
The New Orleans Graduate Medical Assembly, Room 1538,
1430 Tulane Avenue, New Orleans, Louisiana (0112.

r~

■ |

.ckson's CONTACT Jackson - A joint church-social-medical program
New Teleministry is underway in the state capital, offering 24-

hour counseling by telephone. Service offers
•ained workers manning phones around the clock to help depressed,
coholics, drug users, or just about anybody with a problem or
neliness. Program is supported chiefly by church groups, but a
pber of physicians are on advisory and training committees. The
w Jackson CONTACT is the eighth such project activated in U.S.

mputer Loses on Santa Rosa, Calif. - Alfred E. Puller, 71, a
dicare Claim Medicare beneficiary, successfully sued for re-

covery of $3.20 due on a Medicare claim from
lifomia Blue Shield. After meeting with rebuffs in writing the
rt 1-B carrier, Puller took his case to federal court. He proved
at Blue Shield and HEW buried him in paperwork, and the trial
dge ordered payment of the $3.20 and court costs, noting sadly
at "we are losing the battle to the computer. 11

.descent Suicide Chicago - Researchers at Michael Reece Medical
bte Is Rising Center report that adolescent suicide, already

the fifth ranking cause of death in the 15-to-
age group, is rising. Last year, 12 per cent of all suicide at-
fmpts were made by adolescents, and nine out of 10 attempts were
[ de by girls. Males, the study report said, are about twice as suc-
•ssful in death try than girls. Report said that adolescent sui-
' de gestures are not always taken seriously and are "cries for help,"

-A Procedure Code Baltimore - Medicare chief Thomas M. Tierney
ts 5SA Support announced that Part 1-B carriers will adopt

the new AMA Current Procedural Terminology,
five-digit code which describes every medical procedure. It is
: further development of the California four-digit code now in al-
ist universal use. New code will enable error-free communication
i services rendered patients. Only Blue Shield opposes adoption
( new CPT on objection to conversion costs and retraining.

capitals Lose Chicago - A survey by the Hospital Financial

( Computer Use Management Association reveals that a third of

2,800 institutions with data processing units
t little or no support from companies leasing computers to them,
out 600 hospitals have computers, and the rest use outside data
. Dcessing services. Costs range from $1 to a high of $8 per
Itient day. Most hospitals use prepackaged programs for billing,
counting, and recordskeeping.

THE JOURNAL FOR DECEMBER 1970

1 4

MSBH Expands
Rubella Program

Mississippi is making “major progress” against
the crippling effects of Rubella, or German mea-
sles, according to Dr. Durward Blakey, director
of the Division of Preventable Disease Control,
State Board of Health.

Dr. Blakey and Paul M. Turner Jr., supervisor
of the agency’s immunization program, said the
State Board of Health, through August 31, has
given 165,000 doses of Rubella vaccine to chil-
dren from one through 1 1 years of age.

Purpose of the campaign is to keep these chil-
dren from passing Rubella on to their mothers
and thereby causing future babies to be born
mentally retarded or with eye cataracts, heart
defects, liver damage, bone malformation and
other defects.

Last November, Dr. Blakey announced that the
State Board of Health would launch a “massive”
immunization attack against Rubella as part of
an all-out national assault upon the disease which
caused severe birth defects in over 20,000 infants
during the 1964-65 epidemic.

During the past school year, the State Board
of Health, working through the various county
health departments throughout the state, conduct-
ed Rubella immunization programs in 67 coun-
ties, and the agency is now beginning another
series during this school year.

Because of a limited supply of vaccine last
year, the State Board of Health restricted recipi-
ents of the vaccine to children five through seven
in first and second grades of public and private
schools and in Head Start groups and day-care
centers.

In 17 of these 67 counties, children eight
through 1 1 were included in the immunization
programs where additional funds were available
through Appalachia grants and through financial
support at the local level.

Vaccine is now available on a wider scale,
said Turner, because stocks purchased through
federal assistance are sufficient to meet State
Board of Health needs through the present fiscal
year ending next June 30.

“We have 30 county-wide school immunization
programs presently scheduled throughout the
state,” said Turner, “and more are being sched-
uled each day. We hope to reach every county
in the state during the present school year.

“In the process, we expect to immunize over
225,000 more children, bringing the total im-
munized by the State Board of Health to close

to 400,000, not counting the thousands im-
munized by private physicians, who have given
widespread support to this program.”

Of the 30 counties scheduled thus far, said
Turner, seven had no Rubella program last year,
while 23 are conducting their second program,
in order to provide a chance for immunization
for those not immunized last year.

“There was some confusion last year,” said
Turner, “among parents who thought because
their children had been immunized for red mea-
sles (Rubeola) they were also immunized for
Rubella. This is not the case. Two separate im-
munizations are involved.”

Turner said the Rubella vaccine given by the
State Board of Health is “very safe and effective,”
and he said he has had no reports of any adverse
reaction to the vaccine, other than minor rash
or transient pain in the joints in some instances.

He said any county can make arrangements
for a county-wide Rubella immunization program
by getting in touch with the county health de-
partment. He said the Rubella vaccine is now
being offered routinely through every county
health unit in the state.

HISTORY OF MEDICINE

A QUARTERLY JOURNAL co-relating
Medicine and the Arts. Biographical,
historical and literary features by emi-
nent lay and medical authorities; sec-
tion on Medical Antiques and Pictures;
book reviews. 4 issues: $6 annually in-
cluding postage. From: History of Med-
icine Ltd., 78 Queen Victoria Street,
London E.C.4.

Recent contents include:

BRAIN DRAIN by David Furniss

THE MISS HAVISHAM SYNDROME
by Macdonald Critchley

THE ENGLISH FREUD by Vincent
Brome

THOMAS WAKLEY: FOUNDER OF
THE LANCET by David Kerr, M.P.

A MEDICAL HISTORY OF
CHARLES DICKENS

JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION

December 1970, Vol. XI, No. 12

Surgery of the Thymus

PHILIP E. BERNATZ, M.D.

Rochester, Minnesota

Galen, the noted Greek physician of Rome,
observed the thymus in many stages of involu-
tion in his dissections and referred to it as “an
organ of mystery.”1 The accumulated experi-
ence over the centuries has not dispelled this
aura, although as early as 1921 Hammar2 pro-
tested the use of the adjective “enigmatic” for
the thymus when he concluded that its role was
antitoxic. An astounding volume of literature
in the last decade relating the primary impor-
tance of the thymus in developmental immuno-
biology may be considered a revival of the an-
cient Greek concept of this gland as the “seat
of the soul.”

But all the contributions have not been re-
cent. In 1614, Platter introduced the concept of
status thymicolymphaticus, and we are still try-
ing to evict it from the medical literature.1 In
1771, the curious paradox of the involution of
the thymus as peripheral lymph nodes reached
full size was described in ingenious experiments
by Hewson.1 His almost modern conclusions
were that small corpuscles left the thymus by
lymphatic vessels to support peripheral lymph-
oid structures in the prepubertal period. This
aura of mystery about thymic function keeps
us feeling slightly queasy because most of our

Presented before the Section on Surgery, 102nd Annual
Session, May 12, 1970, at Biloxi.

From the Department of Surgery, Mayo Clinic and
Mayo Foundation, Rochester, Minnesota.

practical activities have involved extirpation of
the thymus. Further comfort is not afforded by
Good’s comparative anatomy studies that re-

At the Mayo Clinic thymectomy is offered
to most young patients who have severe my-
asthenia gravis if control by medication has
been poor. There have been remissions or
marked improvement in 74 per cent of
thymectomized patients, and results were
especially good in cases wherein the prior
duration was less than two years. Among
197 cases of thymoma, myasthenia gravis
was associated in 45 per cent; and 20-year
year survival in that group was only 21 per
cent, as compared to 41 per cent in those
with thymoma alone. If the thymoma was
invasive, survival was only 17 per cent at
10 years. The overall survival rates for
197 patients with thymic tumors were 65
per cent for five years, 50 per cent for 10
years, 30 per cent for 20 years, and 17
per cent for 25 years.

vealed the thymus as one of the organs which
permit the phylogenetic development of ani-
mals with advanced tissues, organ systems, and
immune systems.3

From a practical standpoint, however, my col-

DECEMBER 1970

629

SURGERY OF THYMUS / Bernatz

leagues and I have had the opportunity to re-
view the histories of a number of children who
have had thymectomy at our institution. Only
one of these children subsequently had any
problems that might be related to a faulty im-
mune mechanism, this being systemic lupus
erythematosis and chronic ulcerative colitis.

Thymectomy in adult life seems to lead to no
significant impairment of immune capacity, but
Adner and associates4 have reported an immu-
nologic survey on 48 post-thymectomy patients,
and when compared to a control series, the thy-
mectomized patients demonstrated a reduction
in blood lymphocyte count, a reduced cellular
hypersensitivity, and a reduction in immuno-
logic capacity.5 The authors did not describe
any particular clinical problems that might be
related to these serologic findings.

Recent investigations about thymic function
show that thymectomy for myasthenia gravis is
reasonable. Immunologic implications of thymic
function and the designation of “immunologic
suicide” for myasthenia gravis with both etio-
logic and prognostic connotations encourage sur-
geons to continue thymectomy as a mode of
therapy.

SURGICAL HISTORY

The modern era of surgical interest in the
thymus followed a report by Blalock and asso-
ciates6 in 1939 of a patient with myasthenia
gravis from whom a tumor of the anterior me-
diastinum had been removed and who subse-
quently derived benefit with respect to her my-
asthenia gravis. An uneasiness pervaded this re-
port because the authors carefully pointed out
that this case involved a tumor in the region of
the thymus, actually a cyst, in which no histo-
logic evidence of the thymus was found. Much
speculation and presumption was associated
with this report.

At the Mayo Clinic generally, thymectomy is
offered to all young patients, male or female,
who have severe myasthenia gravis and in whom
control has been poor with medication. Patients
with ocular symptoms alone should not undergo
operation because their outlook is good. At the
other extreme, patients who are desperately ill
with myasthenia should not be operated on as
an emergency. Although my colleagues and I
have done this occasionally, the results have
been sufficiently discouraging that we rec-
ommend thymectomy be delayed until reason-
able control of the disease has been gained.
Many presumed myasthenic crises have resulted

from too much medication, and in these pa-
tients, medication must be withheld, respiration i
supported, and gradual control of the myasthe-
nia gravis regained.

Although the anesthetic management of these ,
patients is challenging, anesthesiologists have
not considered their cases as being unusually
formidable. Indeed, the patient with myasthe-
nia gravis is safer in the operating room than
out, because there his airway and ventilation re-
ceive constant attention. Muscle relaxants are
generally avoided, even during intubation, and
light ether analgesia has furnished excellent op-
erating conditions without the need for
amounts involving a curare-like effect.

MEDIAN STERNOTOMY

The operation is accomplished by use of a
median sternotomy. The sternal incision can be
kept low both for cosmetic purposes and for fa-
cilitation of a tracheotomy if necessary. Embry-
ologic derivation from the third branchial
pouch forces the surgeon to remove the more
cephalad portions of the gland in the neck re-
gion but does not require extension of the skin
incision to accomplish this. The rather con-
sistent arterial supply from branches of the in-
ternal mammary artery and venous drainage in-
to the left innominate vein is not formidable
but is annoying if it is not handled properly.

Complete removal of the thymus by the cer-
vical route, as recently revived by Kirschner and
associates,7 has not appealed to us but has theo-
retic advantage. We do not employ tracheotomy
routinely but prefer to select patients who are
ill with bulbar problems or those whose ventila-
tory function is diminished or inadequate. Ven-
tilation can be evaluated prior to removal of
the endotracheal tube, and if ventilation is not
satisfactory, the endotracheal tube can be left
intact for a few more hours to facilitate me-
chanical assistance, with the hope that trache-
otomy may be avoided. If mechanical assistance
is required after 24 to 48 hours, tracheotomy
should be done.

ANTICHOLINERGIC MEDICATION

Experience with these patients has made it
evident that a primary source of postoperative
difficulty is the excessive use of anticholinergic
medication. Our postoperative problems have
decreased since we have stopped employing the
patient’s usual amount of medication, as deter-
mined from the preoperative schedule, and have
used a different philosophy. We now give no
medication unless it is deemed necessary through
frequent evaluation of the patient’s status. This

630

JOURNAL MSM A

need may be less apparent if ventilation is being
supported artificially. Patients seldom require
anticholinergic medication for 24 hours after
operation, but then the need usually becomes ev-
ident and increases for several days, after which
the need may progressively decrease with remis-
sion of the disease.

Valid comparisons of the results of thymec-
tomy in myasthenia gravis require complete ran-
domization of patients. However, we have not
felt such a program to be reasonable and shall
compare the course of thymectomized patients
with the course of those who refused operation
or who were not considered for surgery because
of other circumstances.

At the Mayo institution, of 163 patients with
myasthenia gravis who underwent thymectomy,
74 per cent had remission or marked improve-
ment of symptoms, with better control of the
myasthenic symptoms on less medication.8 Re-
ports from other institutions are similar, though
the type of statistics makes direct comparisons
difficult. For example, 1,355 patients were stud-
ied in a cooperative effort at Massachusetts Gen-
eral Hospital and at Mount Sinai Hospital in
New York, and of these, 188 patients without
tumor had thymectomy and 55 per cent were im-
proved.9 Of the entire group, 75 per cent of
the patients who underwent surgery survived
five years, while only 57 per cent of the treat-
ed medically survived the same period. These
authors reported that the mortality rate for fe-
males with myasthenia gravis treated surgically
was significantly lower than that for females
not undergoing surgery. Their results for males
suggested also that the remission rate was much
higher if thymectomy was done. I agree, and
think that the same may be true for any age
group if the myasthenia gravis is of recent on-
set. My colleagues and I are impressed with the
more favorable results when the duration of
the myasthenia gravis is less than two years.

THYMIC TUMORS

Results with thymoma are more uncertain.
More disagreement and confusion over diagnos-
tic criteria, subclassification, and clinicopatho-
logic correlation have been caused by neoplasms
of the thymus than by almost any other tumor
in the body.10-13 Tumors in the region of
the thymus may be diverse, thus making it dif-
ficult to select a group of tumors that are de-
rived truly from the thymus. Hopefully, our
classification of thymic tumors does not include
all the lymphomatous tumors or tumors of
mesothelial origin (Table 1).

The primary activity of the thymoma that is

of concern is its malignant potential. The his-
tologic structure of the thymic tumors does not
permit ready division into benign and malig-
nant tumors; invasion by the neoplasm is the
most reliable sign of malignancy and was found
in 28 per cent of 197 tumors in one series.15
The surgeon can best judge this at operation.
Unless a pathologist has histologic evidence of
extracapsular invasion, it is sometimes difficult

TABLE 1

CLASSIFICATION OF THYMIC TUMORS

Andritsakis & Sommers, 14
1959

Bernatz, Harrison,
& Clagett ,io 1961

Thymic tumors

f Noninvasive

Epithelial

Thymoma

Undifferentiated

Invasive

Reticular

Spindle cell

Clear cell

Trabecular

Predominantly

Epidermoid

Lymphocytic

Glandular

Epithelial

Adenoacanthomatous

Mixed

Lymphoid

Spindle cell

Embryonic

Fatty

Cystic

Hyperplastic

for him to look at a section of a thymoma and
predict its malignant potential. In fact, this is
one of the bits of circumstantial evidence that
suggest the possible hormonal activity of tumors
of the thymus, because a similar problem can
be found in other neoplasms of endocrine ori-
gin, such as chemodectomas and adrenal and
pancreatic lesions.

In the presence of invasion (27 per cent), a
survival rate of 17 per cent was noted at 10
years, but at 20 years, there were no survi-
vors.15 Among the patients with noninvasive
tumors, and particularly among those patients
who do not have myasthenia gravis, cures can be
discussed because after about the eighth year
following resection the curve for survival paral-
lels that of the normal population, according
to the Berkson and Gage calculation method.16

Patients with invasive tumors invariably died
from complications of local invasion, such as
pericardial tamponade and other cardiorespira-
tory complications. Distant metastasis is rare;
for example, in our series of 197 patients, only
two had distant metastasis.

Consideration of the relationship of survival
to predominant cell type revealed that patients
with spindle cell or predominantly lymphocytic

DECEMBER 1970

63 1

SURGERY OF THYMUS / Bernatz

cell tumors had a much better survival rate than
did those with mixed or predominantly epitheli-
al cell lesions. The long-term outlook for pa-
tients with the epithelial cell type of thymoma
is discouraging. There were no long-term survi-
vors in this group. Interestingly, 51.4 per cent
of the tumors with predominantly epithelial
cells were invasive. However, 14.3 per cent of
the tumors with lymphocytic cells and 15.9 per
cent of the tumors with spindle cells were asso-
ciated with invasion. Tumors of mixed cells had
a much higher incidence of invasiveness, name-
ly 40.8 per cent, indicating the invasive potenti-
ality of epithelial cells; and only 7 per cent of
patients with this cell type survived 15 years.

The prognosis is ominous when myasthenia
gravis is associated with thymoma (45 per cent).
The 20-year survival rate of patients with asso-
ciated myasthenia gravis was 21.3 per cent, or
half the 20-year survival rate for patients with-
out associated myasthenia gravis (41.2 per
cent).15 The follow-up studies, which were
possible in 99 per cent of cases, revealed that
most of these patients died from the complica-
tions of myasthenia gravis rather than from the
local or metastatic effects of the thymic tumor.
The outlook for patients with invasive thy-
moma and myasthenia gravis was approximately
the same; there were no survivors after 18 years.
This was not true for the patient with nonin-
vasive tumors without myasthenia gravis for
whom the 20-year survival rate was 60.9 per
cent; this rate paralleled the normal population
survival.

TUMOR SURVIVAL RATE

The overall survival among 197 patients with
thymic tumors was 65 per cent for five years, 50
per cent for 10 years, 30 per cent for 20 years,
and 1 7 per cent for 25 years.

Results at our institution after thymectomy
for myasthenia gravis are sufficiently encourag-
ing that we have liberalized our indications with
respect to age and sex. Operation is offered to
most patients whose symptoms cannot be con-
trolled by a good medical program, particularly
when the duration of the myasthenia gravis is
less than two years. We have noted good results
in 80 per cent of such patients, with complete
remission in 30 per cent.8

The accumulated experience with thymic tu-
mors does not permit complacency. Factors that
influence the prognosis of the patients with a
thymoma include ( 1 ) presence or absence of in-

vasion, (2) associated myasthenia gravis, and
(3) histologic cell type.

Invasion was present in 28 per cent of the 197
thymic tumors. At 10 years after operation, only
17 per cent of patients with invasive tumors
were alive as compared to 64 per cent of pa-
tients with well-encapsulated tumors. Invasion
is not always easy to determine because the des-
moplastic reaction as well as the inflammatory
reaction around the thymoma may be marked
and may simulate invasion of the tumor. Inva-
sion may be especially difficult to determine
when there is adherence to the pericardium, and
initially the lesion is ominously fixed, as palpat-
ed by the surgeon’s exploring hand. If there is
any question of invasion, the pericardium and
lung (which are the most frequently adherent
tissues, other than pleura) can be readily excised
with the neoplasm. Because thymomas exert
their malignant effects locally, the surgeon must
be aggressive in his resection.

COMPLETE EXCISION

In the presence of associated myasthenia
gravis, a complete excision of the thymus must
be accomplished, along with removal of the tu-
mor. Our experience, as well as the experience
of others, offers adequate justification that the
association of myasthenia gravis and thymoma
is particularly ominous.10 Long-term follow-
up reveals an early toll taken by the invasive
complications and a delayed but equally discour-
aging devastation by the myasthenia gravis.
However, 23 per cent of patients had remission
or marked improvement of their myasthenic
symptoms after removal of the thymus and
thymoma.15

The various clinical syndromes associated
with thymic tumors provide impetus for specu-
lation and research. Agenesis of the erythro-
cytes, acquired agammaglobulinemias, Cushing’s
syndrome, dermatomyositis, and granulomatous
myocarditis may provide perplexing clinical
findings. We can only speculate why removal of
the tumor does not frequently cure or influence
the serologic manifestations, why the thymic tu-
mor and the unusual extrathymic diseases may
appear at different times, and whether the tumor
may damage or alter the function of the re-
maining thymic tissue and prevent emergence
of the immunologically active cells which may
be attributed to thymic function.

Retrospective studies offer little in solving
these puzzles, and we need to study all of these
patients prospectively with everything at our
command, including complete hematologic and
immunologic surveys. So much information has

632

JOURNAL MSM A

been compiled about these patients, and yet so
few definite statements can be made.

CONCLUSION

Of 163 patients with myasthenia gravis who
underwent thymectomy, 74 per cent had remis-
sion or marked improvement of symptoms.
Good results were noted in those who had the
disease less than two years.

Results of up to a 27-year follow-up of 197
patients with thymoma revealed the ominous ef-
fect of associated myasthenia gravis and inva-
sion. The predominant cell type in the thymic
tumor was also an important prognostic factor.
Patients with epithelial-cell tumors had a poor
long-term survival rate (7 per cent). This type
of tumor also had the highest percentage of
gross invasion (51 per cent). Overall survival
rates for the 197 patients with thymic tumors
were 65 per cent for five years, 50 per cent for
10 years, 30 per cent for 20 years, and 17 per
cent for 25 years. ***

Mayo Clinic (55901)

REFERENCES

1. Spees, E. K.: Thymos Primer (narration), J.A.M.A.
207:1436 (Feb. 24) 1969.

2. Hammar: Cited by Spees, E. K.1

3. Good, R. A.; Peterson. R. D. A.; and Gabrielsen.
Ann E.: The Thymus: Current Concepts, Postgrad.
Med. 36:505 (Nov.) 1964.

4. Adner, M. M.; Sherman, J. D.; Ise, C.; Schwab,
R. S.; and Dameshek, W.: An Immunologic Survey
of Forty-eight Patients With Myasthenia Gravis,
New Eng. J. Med. 271:1327 (Dec. 24) 1964.

5. Adner, M. M.; Ise, C.; Schwab, R.; Sherman, J. D.;
and Dameshek, W.: Immunologic Studies of Thy-
mectomized and Nonthymectomized Patients With
Myasthenia Gravis, Ann. N.Y. Acad. Sci. 135:536
(Jan. 26) 1966.

6. Blalock, A.; Mason, M. F.; Morgan, H. J.; and Riv-
en, S. S.: Myasthenia Gravis and Tumors of the
Thymic Region: Report of a Case in Which the
Tumor Was Removed, Ann. Surg. 110:544 (Oct.)
1939.

7. Kirschner, P. A.; Osserman, K. E.; and Kark, A. E.:
Studies in Myasthenia Gravis: Transcervical Total
Thymectomy, J.A.M.A. 209:906 (Aug. 11) 1969.

8. Howard, F.: Personal communication.

9. Schwab, R. S.; Wilkins, E. W., Jr.; Head, J. M.; Pon-
toppidan, H.; and Viets, H. R.: Thymectomy in
Myasthenia Gravis, J.A.M.A. 187:850 (Mar. 14)
1964.

10. Bernatz, P. E.; Harrison, E. G.; and Clagett, O. T. :
Thymoma: A Clinicopathologic Study, J. Thorac.
Cardiov. Surg. 42:424 (Oct.) 1961.

11. Lattes, R.: Thymoma and Other Tumors of the Thy-
mus: An Analysis of 107 Cases, Cancer 15:1224
(Nov. -Dec.) 1962.

12. Wilkins, E. W., Jr.; Edmunds, L. H., Jr.; and Castle-
man, B.: Cases of Thymoma at the Massachusetts
General Hospital, J. Thorac. Cardiov. Surg. 52:322
(Sept.) 1966.

13. Sellors, T. H.; Thackray, A. C.; and Thomson, A. D.:
Tumours of the Thymus: A Review of 88 Operation
Cases, Thorax 22:193 (May) 1967.

14. Andritsakis, G. D.; and Sommers, S. C.: Criteria
of Thymic Cancer and Clinical Correlations of
Thymic Tumors, J. Thorac. Surg. 37:273 (Mar.)
1959.

15. Khonsari, S.; Bernatz, P. E.; Harrison, E. G.; and
Taylor, W. F.: Thymoma: Factors Influencing Prog-
nosis (unpublished data).

16. Berkson, J.; and Gage, R. P.: Specific Methods of
Calculating Survival Rates of Patients With Cancer.
In Treatment of Cancer and Allied Diseases. Volume
1 : Principles of Treatment. Second edition. Edited
by G. T. Pack and I. M. Ariel. New York, Hoeber
Medical Division, Harper & Row, Publishers, Inc.,
1958, pp. 578-589.

YOU KNOW WHO!

A distraught man was standing on the rail of the Pearl River
Bridge at Jackson, proclaiming to the world in a sobbing voice that
he was about to end it all. A police cruiser screeched to a halt on
the bridge, and an officer jumped out and implored the man to
reconsider.

“Think of your family and your church,” the policeman pleaded.

“I have no family, and I do not believe in religion,” the poten-
tial suicide retorted.

“Then think of Archie and the Rebels.”

“Archie who?”

“Jump, you so-and-so, jump!”

DECEMBER 1970

633

When irritable colon feels like this

p -

The blowfish, a small spe
of fish, reacts to stress or
fright by puffing itself up
air. After about a dozen
noisy gulps the belly is bal
shaped and hard. When
replaced in the water the
quickly expelled, and
the fish sinks to the botto

in the presence of spasm or hypermotility,
gas distension and discomfort, KINESED®
provides more complete relief :

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anxiety and tension

Composition: Each chevvable, fruit-flavored, scored tab-
let contains: 16 mg. phenobarbital (warning: may be
habit-forming); 0.1 mg. hyoscyamine sulfate; 0.02 mg.
atropine sulfate; 0.007 mg. scopolamine hydrobromide;
40 mg. simethicone.

Contraindications: Hypersensitivity to barbiturates or

belladonna alkaloids, glaucoma, advanced renal or he-
patic disease.

Precautions: Administer with caution to patients with
incipient glaucoma, bladder neck obstruction or uri-
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be habit-forming.

Side effects: Blurred vision, dry mouth, dysuria, and
other atropine-like side effects may occur at high doses,
but are only rarely noted at recommended dosages.
Dosage: Adults: One or two tablets three or four times
daily. Dosage can be adjusted depending on diagnosis
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be chewed or swallowed with liquids.

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antispasmodic/ sedative/ antiflatulent

The Significance of Analytical Toxicology

in the Treatment of Poisoning

ARTHUR S. HUME, Ph.D. and
JOHN D. BOWER, M.D.
Jackson, Mississippi

The demand for toxicological services has in-
creased tremendously in recent years. The in-
crease in requests for analyses has been the re-
sult of several factors. Increase in the abuse of
drugs in our society is a major factor. It is esti-
mated that over 50 per cent of the teenagers in
the United States have experimented with at
least one drug.1 Overdosage with drugs is one of
the leading causes of death in children under 15
years of age in New York City.

It is difficult to determine the extent of the
abuse of drugs in our own state, but it can be
stated that the use of drugs is certainly greater
than in previous years. The availability of drugs
to small children has increased because a larger
percentage of our population are on maintenance
drugs than in previous years. The number of
self-poisoning cases with drugs, both accidental
and intentional, has increased. In one commu-
nity, where a comprehensive study of incidence
figures are available, the rate of self-poisoned
patients increased 235 per cent between 1962
and 1967. 2

More and more of these cases are multi-agent
overdosages; that is, two or more drugs are pres-
ent to produce toxic response. Therefore, the need
for the analysis of body tissue for drugs and other
agents has increased greatly in recent years. It is
of the utmost importance in some cases of mixed
poisoning that all the agents be recognized. For
example, the attending physician should be aware
that he is treating an overdosage of amitriptyline
and perphenazine, rather than amitriptyline alone,

From the Departments of Medicine and Pharmacology
and Toxicology, University of Mississippi School of
Medicine, Jackson, Miss.

for the treatment of the two situations would differ
greatly.

Demand for toxicological services has in-
creased greatly in recent years. Increased use
of drugs and subsequent overdosage and poi-
soning problems are primary factors in the
increase. The authors discuss acute and
chronic analytical toxicology at UMC and
specific cases treated there.

In cases in which combinations of alcohol and
drugs which produce convulsions are present, the
choice of anti-convulsants should be based some-
what upon the possibility of potentiating the
central nervous system depression of the alcohol.
Consequently, it is necessary to screen the patient
for alcohol and drugs to become aware of all the
possibilities.

Analytical toxicology at the Medical Center
may be divided into two categories, acute and
chronic. In acute toxicology cases, determinations
of the character of the toxic substance and its
quantity can be life saving in the treatment of
over-dosages cases, for the treatment can then
be more specific. The specimens for analysis are
processed at the University Medical Center on an
emergency basis. The analysis revealing the caus-
ative agent may require 30 minutes to several
hours, depending upon the nature of the toxic
agent. These acute cases may include inorganic
compounds (boric acid, phosphorous or arsenic,
etc.) or organics (pesticides or drugs such as

636

JOURNAL MSM A

barbiturates, tranquilizers, alcohol or narcotics,
etc.). The most frequently encountered cases of
overdosages at the University Hospital do not in-
volve barbiturates as in previous years, but are
more likely to contain combinations of either al-
cohol and/or tranquilizers and sedatives.

In cases in which the causative agent or agents
is not known, the specimen is submitted to a
“general" toxicological screening procedure which
first involves a qualitative analysis for alcohol or
other volatiles. Then the specimen is subjected to
a separatory analytical procedure which separates
acidic, basic, neutral and narcotic drugs.

In addition, the sample will be examined for
heavy metal by atomic absorption spectrophotom-
eter, if this determination is deemed necessary
at this point. An analytical toxicology laboratory
is requested to analyze for a wide array of or-
ganic and inorganic substances. The method of
analysis selected is dependent upon the situation,
the history of the patient and the suspected toxic
agent. Gas chromatography is employed for the
determination of volatiles, i.e. alcohols, am-
phetamine, some sedatives and other drugs. Ul-
traviolet spectophotometry is utilized for the anal-
ysis of organic drugs in general. Thin layer chro-
matography and infrared spectrophotometry are
also employed in specific situations. Spectrophoto-
flurometry is utilized in the determination of hal-
lucinogenic agents as LSD, psilocybin, mescaline
and others.

TOXICOLOGICAL ANALYSES

The results of toxicological analyses are con-
sidered essential in the evaluation of a patient in
an acute toxic condition to determine if the con-
centration of the poison is sufficiently toxic to re-
quire rapid removal by hemodialysis to insure
survival of the patient. Not only is the qualitative
and quantitative determination of the poison help-
ful, but the dialyzability and the removal rate of
the poison by hemodialysis can be of aid in the
treatment of the poisoned patient. The toxicology
laboratory at the University of Mississippi cooper-
ates closely with the Artificial Kidney Unit at the
Medical Center in this respect.

A few typical acute cases involving toxicology
are described below:

A female patient was admitted with a history
of phenobarbital ingestion. She was comatose and
areflexic. An analysis of a blood sample revealed
a concentration of 13 mg. per cent phenobarbital.
A blood level such as this and clinical symptoms
as manfested are considered criteria for necessary
hemodialysis. The patient was placed on dialysis
until she awakened.

A female patient, six months pregnant, was ad-

mitted to the University Hospital with a history
of acute onset of symptoms of loss of conscious-
ness, ataxia, etc. Her condition was considered
neurological in origin until a blood level of five
mg. per cent phenobarbital was determined. The
patient was treated as a drug overdose case with
supportive therapy.

A male patient was admitted in a severe co-
matose condition with a history of possible in-
gestion of tranquilizer, aspirin and narcotics. How-
ever, toxicological analysis of blood sample re-
vealed that he had ingested none of the suspects,
but had a sufficient quantity of a non-narcotic
analgesic and alcohol to produce the central ner-
vous system depression observed. It was deter-
mined that the patient could be treated adequate-
ly with supportive therapy.

ACUTE CASES

Perhaps the greatest contribution a toxicology
laboratory can make is in acute cases in which
the history of the patient is inadequate or obscure.
This situation occurs quite frequently in cases
in which the patients are children, and it is not
known whether the symptoms are the responses
of a foreign agent or are the results of other dis-
orders.

In areas of chronic toxicology, the requests of
heavy metal analysis far exceed request for other
examinations in this area. A number of cases
of poisoning have been uncovered by the deter-
mination of lead, mercury or arsenic in urine
and/or blood. It is of particular value to screen
the urine of people who are exposed to lead in
their occupation or who have histories of chronic
ingestion of “moonshine” whisky.

In addition, the laboratory receives requests to
monitor drug levels of therapeutic agents being
used chronically in which a certain blood level is
necessary or toxic levels are to be avoided. An
example of these are patients receiving aspirin,
sulfonamides, lithium and tranquilizers.

PESTICIDE PROBLEMS

An area of immediate need is toxicology of
pesticides. Mississippi is one of the leading states
in the use of pesticides. Our population is exposed
frequently and numerous cases of poisoning have
already been reported. With the knowledge that
massive overdosages of pesticides have occurred
in other parts of the world, the facilities in the
state for the detection of pesticides should be
expanded.

The toxicology laboratory also functions in de-
terminations of the cause of death where drugs
or poisons are suspected. Recently, samples of
blood, gastric contents and liver were submitted

DECEMBER 1970

637

Analytical Toxicology / Hume et al

for examination. A barbiturate was detected in
large concentration in the blood, residue of bar-
biturate capsules were identified in the gastric
content and a relatively low level of drug was
found in the liver. From the relationships of
these findings, it can be surmised that this person
had ingested a large amount of barbiturate just
a short time prior to death. This introduces the
probability of suicide.

It is apparent from requests for toxicological
analyses at the University Hospital that a labora-
tory which could make toxicological analyses

available to physicians on a statewide basis is
essential to the well-being of the people of the
state. With expansion of present facilities, the
laboratory at the University could handle the
medical toxicology needs for the state and con-
tinue to aid the crime laboratories in the analyses
of drugs of abuse and biological tissue for drugs
and/or poisons. ★★★

2500 North State Street (39216)

REFERENCES

1. Chanin, A.: Toward Understanding Teenagers, Al-
ternative to Drug Abuse, Clin. Ped. 8:6, 1969.

2. Kessel, G. R.: Self-Poisoning, Part I, Br. Med.
2:1269, 1965.

PAR AT MATURITY

Rearing a child to age 18 is a costly process, estimates In-
surance Economics Survey, the official publication of the Insur-
ance Economics Society of America.

The study says that it costs $580 to be born, $2,490 for
medical and health care, $8,020 for food, $3,790 for clothing
(discounted for hand-me-downs), $8,590 for housing, $3,800
for transportation, $860 for personal care (haircuts and the like),
$1,920 for recreation, all for a total of about $30,000.

Then there is $20,000 for college, about $??? for the wedding,
$??? for the loan, and $580 for the first baby. . . .

638

JOURNAL MSMA

Use of Artificial Kidney in
Cases of Poisoning

JOHN D. BOWER, M.D., and
ARTHUR S. HUME, Ph.D.
Jackson, Mississippi

Since the installation of the Artificial Kidney
Unit at the University of Mississippi Medical
Center in 1967, the unit has been requested to
assist in the treatment of numerous cases of poi-
sonings admitted to the University Hospital. The
purpose of this paper is to familiarize the reader
with the use of the artificial kidney in rapid re-
moval of poisons.

The artificial kidney was first used clinically
for the treatment of acute poisoning in 1950.
Since that time, the list of dialyzable poisons has
grown to such an extent that a detailed discussion
of all these substances would not be possible.1

It is most important that the reader understand
at the onset that hemodialysis does not substitute
for good supportive care of the poisoned patient.
Dialysis is the most rapid means of removing a
poison from the blood, but prompt gastric evac-
uation and maintenance of an adequate airway
and other supportive therapy cannot be over-
emphasized.

In cases of poisoning, the question “Is this
poison dialyzable?” must be answered. The fol-
lowing criteria for judging the applicability of
dialysis in the therapy of poisoning were estab-
lished by Schreiner:2

1. Molecules should diffuse through the dialyz-
ing membrane, such as cellophane or peritoneum,
from plasma water and have a reasonable re-
moval rate or dialysance.

2. The drug must be distributed in plasma
water or accessible body fluid compartments, or

From the Departments of Medicine and Pharmacology
and Toxicology, University of Mississippi School of
Medicine, Jackson, Miss.

readily equilibrate with the circulating volume.
Tight protein or tissue binding limits dialysis.
This limitation is diminished if the bound or
loculated portion can equilibrate with plasma wa-
ter during the usual time of clinical dialysis.

Hemodialysis can safely and effectively
remove many intoxicating agents from the
poisoned patient. These include aspirin and
barbiturates which are readily removed,
many sedatives which are less readily re-
moved and phenothiazines which are poorly
removed. Some antibiotics are also readily
dialyzed. The Medical Center Artificial Kid-
ney Unit in the Department of Medicine is
equipped to do both lipid and aqueous he-
modialysis in those patients in whom con-
servative management will not suffice.

3. There should be a relationship between the
blood concentration, the duration of the body’s
exposure to the chemical, and its ultimate clini-
cal toxicity. This has been termed the “time-dose-
cytoxic relationship.”

4. The amount of poison dialyzed should con-
stitute a significant addition to the normal body
mechanisms for dealing with the particular poison
under the physiologic circumstances which may be
encountered under clinical conditions of intoxi-
cation. The mechanisms include metabolism, con-
jugation, enzyme induction, pharmacologic antag-
onism, and elimination of the substance by bowel
and kidney. The physiologic circumstances may

DECEMBER 1970

639

ARTIFICIAL KIDNEY / Bower et al

include shock, oliguria, and poor liver perfusion.
Metabolic rates may not be extrapolated from
the normal dog to the sick patient.

The indications for hemodialysis vary quite
widely but the clinical symptoms of severe cen-
tral nervous system depression and a toxic blood
level of barbiturate as quantitated by analysis
are considered indications for hemodialysis. A
blood level of 3.5 mg. per cent or ingestion of
3.0 gm. of a short-acting barbiturate is an indi-
cation of severe intoxication. A blood level of
8.9 mg. per cent or the ingestion of 5.0 gm. of
long-acting barbiturates is indication that hemo-
dialysis may be necessary. This is particularly
true when alcohol or other drugs may be present.
In general, the patients treated by hemodialysis
have a 10-30 times faster removal of barbiturates
than by the other most efficacious method, which
is forced diuresis. Dialysis definitely shortens the
duration of coma and increases survival rate.
Although the rate of removal of short acting bar-
biturates is significantly less than for the long
acting preparations, due primarily to their pro-
tein binding, it is felt that even here the small
quantity removed by hemodialysis has consider-
able pharmacologic and clinical significance.

GLUTETHIMIDE HEMODIALYSIS

Hemodialysis for glutethimide intoxication has
proven to be much less effective than it is for
phenobarbital poisoning. This is preferentially se-
several factors. Glutethimide is preferentially se-
questered in body fat where the drug may be con-
centrated 10-15 times that of the blood concentra-
tion. Glutethimide is also protein bound and the
amount recovered by hemodialysis is small rela-
tive to the ingested dose. Blood levels do decline
more rapidly with dialysis than with conservative
therapy and it is felt that it definitely shortens the
duration of coma. Internal recycling such as might
occur through the biliary system with intestinal
re-absorption sometimes will require a second or
even a third dialysis, when the patient goes back
into coma after being awakened by dialysis.

Other methods that have been attempted to
facilitate removal consist of biliary drainage and
induction of diarrhea with sorbital. Neither of
these have proven to be extremely efficacious.
Patients who have ingested an overdose of glu-
tethimide have a tendency to develop pulmonary
edema and this tends to contraindicate osmotic
diuresis. Peritoneal dialysis is much less efficient
than hemodialysis, but several modifications of
this have increased its efficiency. Some investi-
gators add fat emulsions to the peritoneal fluid

and have enhanced markedly the rate of removal
of glutethimide by this method. Still others have
hemodialyzed patients using only fat emulsions
as the dialysate with a significant improvement.
Fat emulsions have definitely increased the clear-
ance during both hemodialysis and peritoneal
dialysis. It is felt that dialysis is definitely indi-
cated when 10 or more gm. of glutethimide has
been ingested or the blood level is in excess of
3.0 mg. per cent.

TRANQUILIZER INTOXICATION

It is somewhat difficult to discuss the effective-
ness of dialysis in the management of intoxication
with tranquilizers since overdosage of any one
tranquilizer is relatively rare. Good reports have
been published for the dialysis of paraldehyde,
methpyrlon (Noludar®), phenelzine (Nardil®)
and primidone (Mysoline®). Fair results have
been reported in the dialysis of pargyline hydro-
chloride (Eutonyl®), imipramine (Tofranil®),
amitriptyline (Elavil®) and ethchlorvynol (Pla-
cidyl®). Dialysis studies of the phenothiazine
group (chlorpromazine, chlorproperazine) have
shown that hemodialysis is not very effective. It
is felt that the high percentage of protein binding
interferes with the transference from blood to di-
alysate. The dialysis of chlordiazepoxide (Lib-
rium®) and diazepam (Valium®) are reported as
poor.

Considerable success has been observed in the
Artificial Kidney Unit at the University of Mis-
sissippi Medical Center with the use of lipid di-
alysis for ethchlorvynol (Placidyl®). Soybean oil
was used as the dialysate bath rather than water.
This resulted in a threefold increase in removal
rate of ethchlorvynol.

SALICYLATE REMOVAL

Acetylsalicylic acid has been studied extensive-
ly being the original agent that was experimental-
ly removed from intoxicated dogs in 19 13. 3 The
artificial kidney removes salicylates three to five
times faster than the human kidney. Survival has
been reported after the ingestion of as much as
150 and even 210 gm. when treated with dialysis.
It is recommended that patients with blood levels
above 90 mg. per cent be strongly considered for
dialysis for two reasons. First of all, dialysis will
correct the severe state of acidosis that exists and
also correct the associated electrolyte abnormali-
ties. Dialysis will also prevent the later compli-
cations of salicylate intoxication, namely bleed-
ing.

Peritoneal dialysis and exchange transfusion
have been recommended, but hemodialysis proves
to be much more efficacious than either of these

640

JOURNAL MSM A

methods even when albumin was added to the
peritoneal dialysis fluid.

Methyl salicylate intoxication has also been
treated successfully on several occasions with he-
modialysis. Dextro propoxyphene hydrochloride
(Darvon®) has also been treated successfully
with hemodialysis.

Clinically, ethyl alcohol would rarely, if ever,
require hemodialysis except after massive inges-
tion with severe life threatening intoxication.
There have been several patients, however, who
were inadvertently dialyzed for ethyl alcohol in-
toxication that were presumed at the onset to be
intoxicated with methyl alcohol. One case was re-
ported where the blood level of ethanol was 284
mg. per cent and fell to 46 mg. per cent within
three hours after being placed on the artificial
kidney. The plasma concentration of ethyl alco-
hol decreases 6-1 1 times faster with dialysis than
spontaneously and the level of methyl alcohol de-
creases 40-60 times faster with dialysis. There are
two indications for promot dialysis in methyl al-
cohol intoxication. One is to accomplish rapid
removal of the methyl alcohol or its degradation
products and the second is to correct the severe
metabolic acidosis that exists. Hemodialysis can
alter the course of the visual impairment that
follows methyl alcohol intoxication.

ETHYLENE GLYCOL

Ethylene glycol (permanent antifreeze) is a
frequently encountered substance that is acci-
dently ingested. Here again, there are two rea-
sons to promptly place this type of patient on the
artificial kidney as soon as the diagnosis is made.
One is that ethylene glycol has a direct nephro-
toxic effect that will cause acute renal failure if
not removed promptly and another is the acidosis
from ethylene glycol intoxication. This can be cor-
rected quite promptly with dialysis. It is felt that
methanol and ethylene glycol are best managed
by prompt and early hemodialysis when this
treatment is available.

Accidental salt poisoning can be handled either
by the artificial kidney or with peritoneal dialysis.
The serum sodium has been promptly lowered
in cases of hypernatremia in several documented
cases with favorable results being reported. The
correction of hyponatremia by dialysis has also
been well-documented many times. Potassium can
be handled very promptly by hemodialysis. This
is done in two ways. First of all there is a rapid
net removal of potassium from the blood stream
plus a prompt shift of potassium back into the in-
tracellular compartment if systemic acidosis is a
contributing factor. Many acute and chronic re-
nal failure patients have been saved from death

due to hyperkalemia by the artificial kidney. Mag-
nesium intoxication is also seen in this group of
patients and can be handled quite readily with
the artificial kidney. Peritoneal and hemodialysis
have also been used to manage acute hypercal-
cemia crisis quite successfully.

A good response to dialysis has been noted in
cases of intoxication due to streptomycin, kana-
mycin, vancomycin, penicillin, sulfamethoxypyrid-
azine, isoniazid, and cycloserine. Methacillin, ox-
acillin, tetracycline, chloramphenicol, and colis-
tin are very poorly removed by dialysis. Dialysis
has also been used to treat the hemolytic anemia
associated with sulfamethoxypyridazine ingestion.
Information on the dialysance of antibiotics is
accumulating very rapidly due to the recent em-
phasis on the maintenance of life in chronic
uremia by dialysis and transplantation.

THIOCYANATE INTOXICATION

Hemodialysis has been used successfully in the
treatment of thiocyanate intoxication as well as
sodium chlorate and potassium chlorate intoxica-
tion. It has also been used to manage the methe-
moglobinemia due to aniline dye poisoning. Boric
acid poisoning has also been treated successfully
with dialysis. Carbon tetrachloride likewise has
been treated successfully with dialysis following
accidental ingestion. In one instance where several
hundred ml. of carbon tetrachloride were ingest-
ed, prompt institution of hemodialysis prevented
both hepatic and renal insufficiency.

Digitalis is very poorly dialyzed. To the con-
trary, severe fatal cases have now been reported
where digitalis intoxication developed while the
patient was on dialysis. This was due to a sud-
den shift in serum potassium. This is a docu-
mented potentially lethal complication of dialysis.
Sodium citrate and dextroamphetamine have
both been treated by the artificial kidney with
good results. Atropine poisoning failed to respond
to hemodialysis.

ETHCHLORVYNOL

At the University of Mississippi Medical Cen-
ter the most common intoxicating agent seen is
ethchlorvynol (Placidyl®). Few of these patients
have actually required hemodialysis, but it is ap-
parent that more suicide is being attempted with
this compound than with the barbiturates. We
have also dialyzed several patients for barbiturate
and aspirin intoxication. We have seen several
methyl alcohol intoxications, as well as carbon
tetrachloride and gasoline.

The Artificial Kidney Unit is equipped to do
toxicology dialysis using both aqueous and lipid
bath solutions. As the experience of the person-

DECEMBER 1970

641

ARTIFICIAL KIDNEY / Bower et al

nel involved with the operation of the dialysis
unit has increased, the actual number of patients
requiring hemodialysis has decreased. It was once
felt that if a patient was unconscious to the extent
that access could be achieved to the blood stream
without the use of local anesthesia, then hemo-
dialysis was indicated. It is felt now that with in-
tensive nursing care, this criterion is no longer ap-
plicable. It is, however, safe to state that dialysis
is usually not indicated if the patient responds to
the pain of a cut down or needle puncture.

The artificial kidney is currently proving itself
to be an accepted means of therapy for the man-
agement of many toxicological problems. It is in
no way a substitute for conventional medical
management, nor should it ever replace such es-
sentials as gastric lavage, maintenance of airway,
and general supportive care of the comatose pa-
tient. Dialysis may be looked upon as the defini-
tive method for management of a toxicology prob-
lem. This is particularly true if the patient has
become hypotensive and is incapable of main-
taining liver and kidney blood flow. This would
result in an inability to remove the substance by
normal mechanisms. Dialysis should be consid-
ered in any comatose patient even with adequate
hepatic and renal function if there are existing
complications of coma itself. An example of this
would be in a patient with extensive pneumonia
and a prognosis of prolonged coma. The prompt
removal of offending agents that are capable of
direct tissue toxicity is also indicated. If the pa-
tient has ingested ethylene glycol, methyl alco-
hol, or carbon tetrachloride, then immediate di-

alytic intervention is indicated even in the ab-
sence of coma as these agents are capable of pro-
ducing direct tissue injury.

For these reasons, precise analytical determina-
tion of blood levels is essential to the manage-
ment of the intoxicated patient. Although the
hazards of hemodialysis are minimal, exposing
any patient to this procedure without there being
a good chance of benefiting the patient is ob-
viously contraindicated.

The precise role of dialysis in the management
of poison and drug intoxications remains un-
known. Our experience leads us to believe that
certainly not all patients with drug overdose are
candidates for hemodialysis. Neither do we feel
that dialysis should in any way substitute for con-
servative medical management. There is a group
of patients, however, in whom medical manage-
ment will not suffice. It is this population in whom
early intervention with hemodialysis is indicated.

2500 North State Street (39216)

The authors would like to acknowledge the work of
Dr. George E. Schreiner, editor of the Transactions of
the American Society for Artificial Internal Organs, for
his continuing work in the field of the dialysis of poisons
and drugs. His annual review of the literature, as well
as his personal contributions, has proven indispensible
to those of us involved in this field.

REFERENCES

1. Schreiner, G. E.: The Role of Hemodialysis (Arti-
ficial Kidney) in Acute Poisoning, Arch. Intern. Med.
102:896-913 (Dec.) 1958.

2. Schreiner, G. E.: The Dialysis of Poisons and Drugs,
Trans. Amer. Soc. Artif. Int. Organs 16:544, 1970.

3. Abel, John J., Rountree, L. G. and Turner, B. B.:
On the Removal of Diffusible Substances from the
Circulating Blood by Means of Dialysis, Trans, of
the Assn, of Amer. Physicians 28:1914.

COLLECTIVE SECURITY

At a meeting of the local American communist cell, the com-
rades were discussing plans for world revolution. The chairman
asked for comment and observations.

“Comrade chairman,” timidly inquired a member, “what will
happen to our unemployment compensation when we have over-
thrown the imperialist facists in Washington?”

642

JOURNAL MSMA

NATIONAL AND REGIONAL

American Medical Association, Annual Conven-
tion, June 20-24, 1971, Atlantic City, Clinical
Convention, Nov. 28-Dec. 1, 1971, New Or-
leans. Ernest B. Howard, Executive Vice Presi-
dent, 535 N. Dearborn St., Chicago, 111. 60610.

STATE AND LOCAL

Mississippi State Medical Association, 103rd An-
nual Session, May 3-6, 1971, Biloxi. Mr.
Rowland B. Kennedy, Executive Secretary,
735 Riverside Drive, Jackson 39216.

Mississippi Academy of General Practice, Annual
Assembly, June 24-26, 1971; Biloxi. Miss Lou-
ise Lacey, Executive Secretary, P.O. Box 3112,
Jackson 39207.

Amite-Wilkinson Counties Medical Society, Third
Monday, March, June, September, December.
James S. Poole, Centreville, Secretary.

Central Medical Society, First Tuesday, January,
March, May, September, November, 6:30 p.m.,
Primos Northgate Restaurant, Jackson. Robert
P. Henderson, Suite B-6, Medical Arts Build-
ing, Jackson, Secretary.

Claiborne County Medical Society, 1st Tuesday
each month, 6:00 p.m., Claiborne County
Hospital, Port Gibson. D. M. Segrest, Port
Gibson, Secretary.

Clarksdale and Six Counties Medical Society,
Third Wednesday, April and First Wednesday,
November, 2:00 p.m., Clarksdale. Walter T.
Taylor, P.O. Box 1237, Clarksdale, Secretary.

Coast Counties Medical Society, First Wednesday,
January, March, May, September and Novem-
ber. C. Hal Cleveland, P.O. Box 1018, Gulf-
port, Secretary.

Delta Medical Society, Second Wednesday, April
and October. Walter H. Rose, 122 E. Baker
St., Indianola 38751, President.

DeSoto County Medical Society, Third Thursday,
February and August, 1:00 p.m., Kenny’s Res-

taurant, Hernando. Malcolm D. Baxter, Jr.,

Baxter Clinic, Hernando, Secretary.

East Mississippi Medical Society, First Tuesday,

February, April, June, August, October, and
December. Reginald P. White, East Mississip-
pi State Hospital, Meridian, Secretary.

Adams County Medical Society, First Tues-
day, February, April, June, August, October,
and December, Eola Hotel Roof, Natchez.

Walter T. Colbert, Jefferson Davis Memorial
Hospital, Natchez, Secretary.

North Central District Medical Society, Third
Wednesday, March, June, September, and De-
cember. James E. Booth, Eupora, Secretary.

Northeast Mississippi Medical Society, Second
Tuesday, March, June, September, and Decem-
ber. S. Jay McDuffie, Nettleton, Secretary.

North Mississippi Medical Society, First Thurs-
day, April and October. Cherie Friedman,

1004 Jackson Ave., Oxford, Secretary.

Pearl River County Medical Society, Second Mon-
day, March, June, September, and December.

J. M. Howell, 139 Kirkwood St., Picayune,

Secretary.

Prairie Medical Society, Second Tuesday, March,

June, September, and December. A. Robert
Dill, 1001 Main Street, Columbus, Secretary.

Singing River Medical Society, Third Monday, r-

January, March, June, September, and Decem-
ber. Donald E. Dore, Singing River Hospital,

Pascagoula, Secretary.

South Central Mississippi Medical Society, Second ;

Tuesday, March, June, September, and Decem-
ber. Julian T. Janes, Jr., 304 Clark, McComb,

Secretary.

South Mississippi Medical Society, Second Thurs-
day, March, June, September, and December.

W. B. White, Medical Arts Bldg., Laurel, Sec-
retary.

West Mississippi Medical Society, Second Tues-
day, January, April, July, and October, 7:00
p.m., Old Southern Tea Room, Vicksburg.

Martin E. Hinman, the Street Clinic, Vicks-
burg, Secretary.

DECEMBER 1970

643

Radiologic Seminar CII

Paget’s Disease

T. SCOTT McCAY, M.D.
Jackson, Mississippi

Paget’s disease, or osteitis deformans, is an os-
seous condition of unknown etiology and for
which there is no specific treatment.

The disease was first described by Sir James
Paget in 1877 and is relatively common, affect-
ing 3 per cent of all persons over age 40. Males
are more frequently affected than females by
a ratio of two to one.

Symptoms encountered most frequently are
localized pain in the area of skeletal involve-
ment and fatigue. When the skull is involved
there may develop basilar invagination, a condi-
tion wherein softening of the bones of the base
of the skull leads to settling of the skull on the
cervical spine, which may lead to neurological
complications. Symptoms of this disease develop
gradually since it is a slowly progressive process.
The disease may be limited to a single site or
may involve multiple areas of bone.

The basic pathology involved in Paget’s dis-
ease consists initially of replacement of normal
bone by a very vascular fibrotic tissue. There
follows a reparative process wherein osteoblas-
tic activity is quite disorganized leading to de-
velopment of a characteristically coarsened tra-
becular pattern in the involved bone. Frequent-
ly, there will develop an expansion of the af-
fected bone during the process of abnormal re-
pair. Finally, when the disease becomes inactive,
the involved bony structures will present a dif-
fusely sclerotic appearance, so-called “ivory
bone.”

Sponsored by the Mississippi Radiological Society.
From the Department of Radiology, St. Dominic-Jackson
Memorial Hospital.

While this disease is basically a progressive
process, frequently it is possible to divide the
disease into three separate stages based on x-ray
appearance. Initially one sees a lytic type defect.
This appearance is most often seen in the skull
where a localized, well defined, washed out area
of deossification is seen. Next one sees begin-
ning of the reparative process, wherein mixed
lytic areas of demineralization are seen along
with areas of new bone osteosclerosis. This is
the classical x-ray pattern.

Finally as the disease becomes quiescent there
develops a diffuse sclerosis producing the “ivory
bone” x-ray appearance. When long bones are
involved, the disease always extends to one end
of the bone. Bowing deformities are frequent
in long bones secondary to weight bearing stress.
Fractures are relatively frequent, but heal readi-
ly-

:

Differential diagnosis of Paget’s disease from
metastatic tumor can at times be difficult.
Usually, the coarsened trabecular pattern of
Paget’s disease, which one does not see in osteo-
blastic metastatic disease, will provide the dis-
tinguishing clue.

Among the complications seen in this disease
are fractures of the involved bones and rarely
sarcomatous degeneration. Also, particularly if
there is widespread disease, during the destruc-
tive phase there will be hypercalciuria which
may lead to renal calculi. Occasionally conges-
tive heart failure develops secondary to shunt-
ing of blood through the hypervascular areas of
affected bone. Neurological complications result-
ing from basilar invagination of the skull and

644

JOURNAL MSM A

Figure 7. Note sclerotic appearance of ilium with
disorganized trabecular pattern (upper arrow). Also,
note expansion of ischium (lower arrow). Bony
structures of left side of pelvis are normal.

compression fractures of the spine are also seen.

The presented radiographs are those of a 79-
year-old female who was admitted to the hos-
pital for gastrointestinal complaints. During the
course of a diagnostic work-up skeletal lesions
of Paget’s disease were demonstrated. The pa-
tient was entirely asymptomatic in the areas of
skeletal involvement. The alkaline phosphatase
was found to be moderately elevated, as is often
the case.

In summary, Paget’s disease is a relatively
common bony disorder which may be localized
to one area or may be widespread. Symptoms are
frequently minimal and not uncommonly the
disease is entirely asymptomatic. Often the dis-
ease is first suspected when radiographs obtained

Figure 2. Lateral and AP views of 11th thoracic
vertebra (arrows) demonstrating mixed or combined
changes. Note coarse vertical striations and increased
density. Also note increase in AP and lateral di-
mensions and compression deformity .

for other purposes reveal changes in bones diag-
nostic of the disease. ***

969 Lakeland Drive (39216)

REFERENCES

1. Edeiken, Jack and Hodes, Philip J.: Roentgen Diag-
nosis of Disease of Bone. Baltimore. The Williams
and Wilkins Co., 1957, pp. 6.220-6.236.

2. Meschan, Isadore: Roentgen Signs in Clinical Prac-
tice, Vol. I. Philadelphia, W. B. Saunders Co., 1966.
pp. 373-374, 478-479.

3. Wilmer, Daniel and Sherman, Robert S.: Roentgen
Diagnosis of Paget's Disease (Osteitis Deformans).
Medical Radiography and PhoiO^raphy 42:35-78.
1966.

4. Paul, Lester W. and Juhl, John H.: The Essentials of
Roentgen Interpretation, 2nd Edition. New York,
Hoeber Medical Division. Harper and Row, Pub-
lishers, 1965, pp. 186-188.

CELESTIAL SYNDROME

“I can't understand why I have so many headaches,” the young
patient complained to his doctor. “I don’t drink, smoke, stay out
late or even bother with women. What’s wrong?”

“I’d guess,” was the reply, “your halo is on too tight.”

DECEMBER 1970

645

The President Speaking

‘LPN’s Fight Drug Abuse’

PAUL B. BRUMBY, M.D.
Lexington, Mississippi

In keeping with the times, Mississippi licensed practical nurses
recently held a two-day workshop on drugs and drug abuse. This
in-depth program was well executed by a committee of LPN’s and
their physician advisers. The problems discussed were of deep
concern to the individuals at the workshop and to every hospital,
hospital staff, nurse and physician. In many of the hospitals this
problem has been of great significance and there has been loss and
downgrading of personnel. Too, it has been reported that there
are more Mississippi physicians who are drug users at present than
there has ever been known or suspected before.

After seeing this group, who called themselves The Bedside
Nurses’ Association, we wonder that so many are taking the time,
the effort, and bearing the expense of attending this educational
seminar. We congratulate their continuing educational efforts and
deep interest.

The discussion and examination of these problems range from
the consideration of personality and character defects of the drug
and alcohol addict to the young and adventurous who will try ex-
perimenting once. Why people continue to lean on pills and alco-
hol was among these discussions. The question always comes up of
marihuana smoking. Is it the fore-runner of future habituation and
will it demand a stronger crutch in the future or is it a passing
fad and fancy? Is it primarily a social or a medical problem? Last
year under our Auxiliary Drug Abuse Program, many physicians
made talks at civic clubs and high schools. How much good was
accomplished is uncertain. But most were reassured, after talking
to the high school groups, that this is as fine a generation as our
country has ever produced. The only difference is that the minority
dissidents have the facilities to scream louder than ever before.

Before lifting a finger at nurses about drugs and drug abuse,
we have to take stock of our own situation. In the JAMA in Sep-
tember and the first week in October there were found six physi-
cians whose deaths were caused by self-administered drugs and a
seventh death was attributed to cirrhosis of the liver. We as doc-
tors must take to heart the old cliche as we remind our nurses
that any person who takes a single self-prescribed dose of medicine
has a fool for a physician. ***

JOURNAL MSMA

646

JOURNAL OF THE
MISSISSIPPI STATE
MEDICAL ASSOCIATION

VOLUME XI, NUMBER 12
DECEMBER 1970

The Four Faces of
National Flealth Insurance

I

The year was 1948, and the legislative bodies
of the two nations which bore the brunt of
World War II for the Allies were up to their
political ears in national health insurance. Ex-
cept that in Great Britain, where the proponents
prevailed, they candidly called it socialized med-
icine.

But President Truman’s “no good, do noth-
ing” 80th Congress, the only one with a Repub-
lican-controlled chamber since the 1930’s, beat
down the Wagner-Murray-Dingell bill amid the
hulaballoo of AMA’s gaudy campaign. By 1950,
both the United States and England seemed to
feel that the issue was respectively settled: The
British had their National Health Service as a
permanent fixture on the medical and govern-
mental scenes. Even Churchill’s return to power
with a Conservative parliament didn’t change
that.

In the United States, voluntary prepayment
began its phenomenal growth, and the Eisen-
hower years were times of debate, not action,
over federal care of the aging. Now, it turns
out, the issues were not settled, for Britain con-
tinues to wrestle with a clumsy program giving
little enough service for too many pounds and

pence of taxes. In the United States, Medicare
and Medicaid are here, and the premiere show-
ing of the Great Health Debate is taking shape.
Clearly, national health insurance will be a ma-
jor issue of the 1972 campaigns.

The stakes are high politically and econom-
ically. Of the four major proposals, AMA’s
Medicredit is said to be the least expensive, and
its costs are estimated at $10 billion the first
year. Sen. Edward Kennedy’s (D.,Mass.) pro-
posal could run as much as $77 billion annual-
ly. Present indications are that battle lines will
be sharply drawn with a host of unlikely allies
arrayed against an equally incongruous group-
ing of adversaries. It may be difficult to say ex-
actly who is on whose side.

II

The four major proposals are in formal leg-
islative proposals before the lame duck 2nd Ses-
sion of the 91st Congress where exactly nothing
will happen to or for them. But we can antici-
pate their reappearance in January with the con-
vening of the 92nd Congress in more and elab-
orate versions with sponsors by the score. The
power bases of the measures are the AFL-CIO;
the late Walter Reuther’s Committee of 100, a
UAW-liberal labor coalition; an axis of Sen.

DECEMBER 1970

647

EDITORIALS / Continued

Jacob Javitts (R.,N.Y.), Gov. Nelson Rockefel-
ler, and former HEW Secretary Wilbur Cohen;
and the American Medical Association. In a nut-
shell, these are the proposals:

AFL-CIO Griffiths Program. Entitled the Na-
tional Health Insurance Act of 1970, H.R.
15779 was introduced by Rep. Martha W. Grif-
fiths (D.,Mich.) in behalf of the AFL-CIO. It
would cover all U. S. citizens and any noncitizen
who has resided in the country for a year. Cov-
erage is total and comprehensive, offering pri-
mary and specialty medical services, optometric
and dental services, outpatient care, skilled nurs-
ing home services, home health care, rehabilita-
tion services, and emergency transportation.

The patient’s choice of physician would be
made annually and would remain in effect for
that year. For certain services, including physi-
cian, dental, and home health, a charge of $2
per visit would be made to the patients.

The Griffiths plan visualizes prepaid group
systems and capitation payment, similar to the
British NHS. Payments to hospitals would be
made on a per capita basis with adjustment for
budgeted costs, local economic conditions, popu-
lation makeup, and other factors. The program
would be administered by a National Health In-
surance Board and would be funded by an em-
ployee tax of 1 per cent and an employer tax of
3 per cent on a wage base of $15,000.

The price tag is estimated at $40 billion per
year.

Committee of 100 — Kennedy Program. For-
mally called the Health Security Program, S.
4297 by Sen. Edward Kennedy was blueprinted
by the late Walter Reuther. With no co-pay pro-
visions, HSP would dig deep into the tax till to
provide all physicians’ services, except that sur-
gery could be done only by an appropriately
qualified specialist on proper referral. Skilled
nursing home service would be limited, as under
Medicare, to 120 days per spell of illness.

Dental services would initially be limited to
children but scheduled for expansion to cover
all citizens in time. Except for nursing home
care limitations, no maximums would be set on
other services. Priority would be given to pre-
paid group care delivery under capitation pay-
ments. Fee-for-service, although not prohibited,
would command lowest priority, and when the
trust fund runs low, these payments would be
prorated.

The plan would be financed from three
sources: 40 per cent from general revenue

funds; 35 per cent from employer payroll tax;
and 25 per cent from employee wage taxes.

Cost estimates vary, but $40 to $77 billion an-
nually is the range mentioned most often.

Medicare-J avitts Program. Tagged the Nation-
al Health Insurance and Health Services Im-
provement Act of 1970, S. 3711 by Sen. Jacob
Javitts (R.,N.Y.) carries the blessings of New
York Gov. Nelson Rockefeller and the fine hand
of Wilbur Cohen. Merely an extension of Med-
icare-for-everybody, the program would build
up to coverage of every American by 1973, add-
ing on for the present the disabled, the unem-
ployed, and the poor.

Offering comprehensive care, the Javitts plan
would also provide prescription drugs with a $1
per script patient co-pay. Unlike other programs,
this one requires the Secretary of HEW to pre-
scribe standards of education and licensure for
providers and the qualifications for perform-
ance of major surgery. Although a federal pro-
gram, the HEW could make contracts with states
for local administration. Payments for services
could be optioned to a capitation basis, health
insurance contract, prepaid practice arrange-
ment, or a combination of these.

Social Security would be the financing vehicle,
as is now the case with Medicare, but with a
sharp increase in that portion of the tax for the
health care portion. This would go to 3.3 per

648

JOURNAL MSM A

cent on a $15,000 wage base by 1975 to which
the federal government would add an equal
amount from general revenues.

The program would cost, according to Social
Security Administration estimates, $66 billion
per year.

AMA Medicredit Program. Boasting 20 spon-
sors in the House of Representatives, Medi-
credit, the Fulton-Broyhill bill, H.R. 18567, is
a three-part program providing basic health in-
surance for every American. Part A provides
for issuance of health insurance certificates to
those whose family tax liability is $300 or less
annually. The certificate would be exchanged
for a health insurance contract meeting statu-
tory minimums.

Part B would establish a graduated scale of
tax credits applied to health insurance purchase
based on individual tax liability. It would range
all the way up to the millionaire who would get
10 per cent credit.

Part C is the now well-known Peer Review Or-
ganization (PRO) under which state medical
associations willing and able would have statu-
tory priority in contracting for peer review.

Medicredit offers the least coverage but carries
the lowest price tag: $10 billion a year, accord-
ing to AMA.

Ill

The three camps sponsoring the tax-based
plans, AFL-CIO, Reuther group, and the Javitts-
Rockefeller-Cohen combine, along with others
who will be in the picture before 1972, have
some common preachments which are already
appearing as hard sell support for national
health insurance. The arguments have a popular
appeal which tends to gloss over their failures
in logic. These are the arguments:

The cost of medical care is going so high that
only government can foot the bill. The care-
cost equation is complex, and there are neither
simple explanations of it nor absolute formulae
to solve it.

Generally, insurance is the best means of
spreading a cost risk to the greatest number for
the least unit expense to the assured. This, how-
ever, is not necessarily true in government pro-
grams, because taxation is not now nor will it
ever be the same as an actuarially-determined
premium. Taxation falls heaviest upon those
frequently least able to pay: The young wage
earner, who, for example, must pay ever-increas-
ing Social Security taxes to carry the current pro-
gram.

Government is not necessarily noted for effi-

ciency in medical care financing and administra-
tion, either. So the role of government as the
big daddy for all health care is as dubious as it
is questionable.

The United States, including the medical
community, has historically accepted limited
governmental roles in health care, such as the
Hill-Burton hospital program, public health ser-
vice, research financing, and the like. But the
track record proves anything but competence to
do the whole job.

National health insurance is inevitable. This
is the favorite ploy of the hour, saying, in ef-
fect, it’s coming, so get on the bandwagon.
These same proponents like to say that the Unit-
ed States is the only nation in the world with no
national health system. Closely associated with
this assertion are all sorts of tricky statistics on
infant mortality, care availability, bankrupting
costs, and the like.

Under most NHI proposals, about the only
thing that is inevitable is a back-breaking tax
burden and no guaranteed solutions to health
delivery problems.

National health insurance will deliver more
care. We must be careful to separate medical
care organization from financing when we speak
of supply. All the financing in the world will
not, of itself, train a single additional physi-
cian or build a single new hospital bed.

When we extend the care purchasing base, as
was done with Medicare and Medicaid, we mere-
ly increase the pressures of demand on care or-
ganization.

IV

Just about everybody recognizes that the
winds of change are blowing, and change has oc-
curred in the delivery of medical care in the
United States. But this is not a sufficient reason
to abandon the concept of private care organiza-
tion. Conversely, it is all the reason in the world
to strengthen private organization with innova-
tions built around the integrity of private medi-
cine and its astonishing ability to deliver quality
care.

Not to be lost in the NHI shuffle are peer re-
view under exclusive physician control, medical
association-sponsored care foundations, new
concepts in hospitals with graduated levels of
care intensity, medical manpower extensions in
new allied professional fields, and a host of im-
provements with solid promise.

Of course, nothing is absolute in terms of
comparison, but it seems as if private air lines
in the U. S. offer more and better service than

DECEMBER 1970

649

EDITORIALS / Continued

nationalized air carriers. No telephone system
in the world can compare to our privately op-
erated AT&T, nor will any state-owned automo-
bile industry ever outproduce Detroit.

So if this shoe fits in privately delivered med-
ical care, the nation will be well-advised to try
it on for size. National health insurance is no
panacea, is no economic solution, is no guaran-
tor of care delivery, and is quite expensive. We
will all do well to remember that there is no
such thing as free lunch. — R.B.K.

The Growing Role
of the Joint Commission

The Joint Commission on Accreditation of
Hospitals has quietly grown into a service or-
ganization of a much wider spectrum than its
name implies. Quite possibly, JCAH will be
serving many more medical facilities than short
term acute general and medical hospitals within
the present decade.

The Joint Commission came into being in
1951 when the task of inspecting and accredit-
ing hospitals became more of a burden than the
professional organization originating the idea
could bear. As with so many innovations which
have upgraded medical care in the United
States, hospital inspection and accreditation was
a program of the American College of Sur-
geons.

Begun as a voluntary, self-initiated care im-
provement project, the ACS accreditation pro-
gram remains today essentially the same as ini-
tially conceived and implemented. No hospital
is forced to submit to accreditation inspection,
although it is to the distinct advantage of the
institution to do so.

Now, with vastly expanded activities, JCAH
is sponsored by four organizations: the Ameri-
can College of Physicians, the American College
of Surgeons, the American Hospital Association,
and the American Medical Association. By ap-
portionment of commissioners, actually the vot-
ing directors, no single organization can or does
dominate the commission. The internists and
surgeons have three commissioners each, while
AHA and AMA respectively have seven for a to-
tal of 20 voting members. The organizations
bear their proportionate share of expenses nec-
essary to operate the Joint Commission above
earnings from fees charged.

A scant four years ago, JCAH initiated its
Long-Term Care Facilities Accreditation Pro-
gram. Still another activity, the Accreditation of
Rehabilitation Facilities Program, is now opera-
tional. With the long established, original-pur-
pose hospital program, JCAH now has three im-
portant areas of work.

Two new programs are in developmental
stages: the Accreditation Council for Facilities
for the Mentally Retarded and the Accredita-
tion Council for Psychiatric Facilities. A basic
aim is to get these new activities in full swing
by or before completion of the community
mental health and retardation centers program
which is going great guns throughout the na-
tion.

Strengthening this service expansion by JCAH
is the affiliation of 15 national organizations in
the nursing home, care of the aging, rehabilita-
tion, speech and hearing, voluntary health agen-
cy, and mental health fields. JCAH is consulting
these organizations in developing yardsticks with
which to measure care quality in the new areas
of service.

Over the years, JCAH has been discussed and
cussed, praised and berated, thanked and at-
tacked for its work. By and large, however,
American medicine has agreed that exacting
measures of institutional care quality are desir-
able and that JCAH provides a service which is
essential. Areas of disagreement have generally
centered around how the task should be under-

“ Beautiful opening , Parmillee — only it happens to
be in my arm!”

650

JOURNAL MSMA

taken and not on the goal of the task itself.

The growth of JCAH activities in the exten-
sion and innovation of health care delivery will
be influential and important to patients, physi-
cians, and health service institutions. — R.B.K.

The Doctor Has Everything,

Except Time

With wry humor, a physician was recently
heard to observe that “I could easily attend all
of the meetings of all of the organizations to
which I belong, read all the journals and medi-
cal publications I receive, and fill out all the
forms that now deluge me, but there is one
change I’d have to make: I couldn’t see any pa-
tients.”

The strange and distressing paradox in this
day of superefficiency, of instant communica-
tion, nanosecond information retrieval by com-
puters, and all kinds of assorted miracles of sci-
ence and technology is that the doctor of medi-
cine finds new and additional burdens upon his
shoulders. Every new medical care program
brings with it forms and paperwork — so much
so, in fact, that it is not unusual to find one to
five employees in physicians’ offices whose job is
forms completion.

Staff meetings, local medical societies, the
state association, AMA, a host of specialty soci-
eties, voluntary health agencies, committees, and
just about any meeting of any organization
which pops into the imagination compete sav-
agely for the time of the busy physician. His
daily mail can be measured in pounds rather
than pieces as the medical literature proliferates
to a point of disbelief.

Then there are the throwaway publications,
also without number, the tide of one-time mail-
ings, and other chunks of printed matter clog-
ging the postal pipeline. Now we approach the
era of audio tapes, special frequency radio, and
even TV for medical audiences.

It requires no effort to understand why medi-
cal meeting attendance is steadily decreasing.
For example, more than 64,000 registered at the
1965 AMA annual convention at New York with
just under 25,000 M.D.'s participating. Last
June at Chicago, registration was less than 15,-
000 with only 8,000 physicians present. State
medical associations, nearly all with growing
memberships, show decreases in annual session
registration.

Sooner or later, something will have to give,
because physicians cannot meet the demands up-
on their time which seem to get worse, not bet-
ter. Better communication with the doctor, re-
quiring less of his time, simplification of paper-
work together with a substantial decrease in vol-
ume, and greater efficiencies in serving his or-
ganizational needs are musts in the immediate
future. Many physicians are beginning to feel
that they have enjoyed about as much of this
progress as they can stand. — R.B.K.

Hijacking and
Health Insurance

Air piracy has become a serious and grave
problem for the traveling public, the air line in-
dustry, and the government. At stake in every
such incident are the lives of dozens, property
amounting to millions, and national sovereignty
because every scheduled U. S. airliner beyond
our borders is a flag carrier.

It may be small comfort to those diverted un-
expectedly to Jose Marti International Airport
at Havana, but the chances are that their volun-
tary prepayment or health insurance covers care
of illness and injury which could occur during
the illicit excursion. The Health Insurance In-
stitute reports that “almost all of the newer hos-
pital, surgical, and major medical insurance
company policies apply anywhere on this planet
or in the atmosphere, for that matter.”

HII further explains that air line “hijacking
is not considered an exclusion under these poli-
cies.” The statement is qualified, however, with
the further explanation that “if hijacking were
considered an act of war, insurance benefits
would not be covered.”

Legal precedents to date hold air piracy to be
a felony committed by individuals with jurisdic-
tion vested in the nation in which the crime oc-
curs or whose flag is violated internationally. It
has been speculated that piracy of four aircraft
by Arab revolutionaries could have been held
as an act of war, but the revolutionary groups
have no recognition diplomatically.

The HII report says that either full benefits
would be payable for hijack victims, even in a
nation with which the U. S. has no diplomatic
relations, or else emergency care and special risk
coverage would apply. Medicare does not cover
hijack victims, because the only across-the-bor-
der payments authorized are emergency admis-

DECEMBER 1970

651

EDITORIALS / Continued

sions to certain close by Canadian and Mexican
hospitals.

In recent years, the American tourist has been
attracted to travel-accident policies which usu-
ally cover him while on his foreign junket. Gen-
erally, however, his regular health and medical
coverage is valid so long as he travels by sched-
uled carrier at home or abroad. Ill or injured
travelers should consult the nearest U. S. embas-
sy or consulate when stricken abroad as the most
reliable source of advice for securing needed
medical care.

But without U. S. diplomatic representation
where a purloined airplane might end up, it is
still a little comforting to know that voluntary
health insurance protection goes along, too. —
RB.K.

Can He Do the Job?
Then Hire Him!

“Can the man do the job?” This is the ques-
tion asked by the American Mutual Insurance
Alliance about the handicapped. If the answer
from the prospective employer is in the affirma-
tive, AMIA’s reply is “Hire him!”

There is no stronger supporter of the Presi-
dent’s Committee on Employment of the Hand-
icapped than the insurance industry. Along with
the handicapped who often do not get hired, de-
spite ability and job performance capacity, the
insurance companies are frequently misunder-
stood, and three popularly held myths bear this
out. These are damaging to the employment of
the handicapped, and all center around the im-
paired and workmen’s compensation insurance:

— Handicapped workers are more likely to
have accidents than other employees.

Fact: The U. S. Department of Labor has
the hard data to prove that impaired employees
have fewer disabling accidents than nonim-
paired employees exposed to the same job haz-
ards. The handicapped experience about the
same number of minor injuries on the job as
their whole counterparts. The secret of job
safety, handicapped or not, is proper classifica-
tion and placement.

— An employer’s workmen’s compensation in-
surance premium will rise if he hires the hand-
icapped.

Fact: That any employee has a physical im-
pairment does not make him inherently unsafe

on the job. Workmen’s compensation rates are
based solely on the relative hazards of a compa-
ny’s operations and its accident experience.

— The insurance company “won’t let the em-
ployer” hire the handicapped.

Fact: The best refutation of this myth is in
the insurance companies themselves: They are
among the largest employers of the handi-
capped and leaders in employee rehabilitation.

As modern medicine continues to make con-
tributions toward rehabilitation to bring back
to gainful employment many a worker hitherto
lost to society and himself, physicians can help
dispell myths about employment of the handi-
capped. If the man can do the job, hire him. —
R.B.K.

MISSISSIPPI POSTGRADUATE

INSTITUTE IN THE

MEDICAL SCIENCES

Jan. 18-22, 1971

Cancer Chemotherapy Intensive Course
University Medical Center, Jackson
Jan. 18-22, 1971, beginning at 8 a.m.

Sponsored by The University of Mississippi
School of Medicine postgraduate education
committee, with the support of the Mississip-
pi Postgraduate Institute in the Medical Sci-
ences

Coordinators:

Warren N. Bell, M.D., professor of clinical lab-
oratory sciences, chairman of the department,
and associate professor of medicine, The
University of Mississippi School of Medicine

G. D. Deraps, M.D., instructor in medicine, The
University of Mississippi School of Medicine
In this one-week intensive course, partici-
pants will attend rounds, clinics, lectures,
group discussions and case presentations. Em-
phasis will be on office screening, tumor diag-
nosis, natural history of disease and indica-
tions and treatment of various malignancies.
Registration is limited to a class of five fam-
ily physicians from the 40 enrolled in the Mis-
sissippi Postgraduate Institute in the Medical
Sciences, which is funded by the Mississippi
Regional Medical Program. Unlike the other
intensive courses which will be offered twice

652

JOURNAL MSM A

in the 1970-1971 series, cancer chemotherapy
will only meet for one session.

CIRCUIT COURSES
Southern Circuit

Biloxi — Jan. 6 — Session 1, Howard Memorial
Hospital, 6:30 p.m.

Hattiesburg — Jan. 7 — Session 1, Methodist
Hospital, 6:30 p.m.

Session 1 — Peripheral Vascular Disease
Arteriograms, Dr. Carlos Chavez
Surgical Approach, Dr. J. Harold Conn

Southwest Circuit

McComb — Jan. 12 — Session 2, Southwest Mis-
sissippi General Hospital, 7 p.m.

Session 2 — Carcinoma of the Thyroid, Dr.
Coupery Shands

Presentation and Diagnosis of Hypothy-
roidism and Hypoparathyroidism,
Dr. Herbert G. Langford

FUTURE CALENDAR

November 30-December 4, 1970

Neurological Diseases and Stroke In-
tensive Course
Cardiology Intensive Course

December 7-11

Nephrology Intensive Course
December 11

Infections in Obstetrics and Gynecol-
ogy Seminar

January 6, 1971

Circuit Course, Biloxi

January 7

Circuit Course, Hattiesburg
January 11-15

Neurological Diseases and Stroke In-
tensive Course

January 12

Circuit Course, McComb
January 18-22

Cancer Chemotherapy Intensive Course
February 1-5

Electrocardiography Intensive Course
February 3

Circuit Course, Gulfport
February 4

Circuit Course, Hattiesburg

February 16

Circuit Course, Natchez

February 18

Neurology Seminar

February 23

Circuit Course, Columbus
March 1-5

Gastroenterology, Intensive Course
March 3

Circuit Course, Bay St. Louis
March 4

Circuit Course, Hattiesburg

March 5

Renal Seminar

March 8-12

Nephrology Intensive Course
Cardiology Intensive Course

March 9

Circuit Course, Meridian
April 5-9

Pediatrics Intensive Course
April 6

Circuit Course, Meridian
April 13

Circuit Course, McComb
April 19-23

Radiology Intensive Course
April 20

Circuit Course, Natchez
A pril 2 7

Circuit Course, Columbus
May 3-6

Mississippi State Medical Association,
Biloxi

May 11

Circuit Course, Meridian

William L. Bass, Jr., a native of Laurel, has
been appointed full-time director of the Coast-
al Mental Health Association.

Tom H. Blake of Jackson recently returned
from a six-day bear and goose hunt to Naknek.
Alaska.

DECEMBER 1970

653

PERSONALS / Continued

Edgar E. Bobo of Jackson has been elected
chief of staff at Rankin General Hospital for
the coming year. Other new officers are Charles
Williams, vice chief of staff; Robert Rester,
secretary; and Allen Hollis, Executive Com-
mittee member.

Albert E. Breland, Jr., a native of Hatties-
burg, has joined the staff of the Veterans Ad-
ministration Center in Jackson. Dr. Breland is
a graduate of the University of Mississippi
School of Medicine and completed his intern-
ship and neurology residency there.

Eugene A. Bush of Laurel was named Alumnus
of the Year of Jones County Junior College at
recent homecoming activities at the college.

Carlos M. Chavez of Jackson has become a
Fellow of the American College of Chest Phy-
sicians.

Robert D. Currier of Jackson and UMC pre-
sided over a meeting of the Central Society for
Neurological Research in St. Louis recently. Dr.
Currier is currently president of the society.

Thomas H. Gandy of Natchez presented slides
from his personal collection for a program on
“Natchez Under the Hill” at the 15th annual
Louisiana Art and Folk Festival in Columbia.

Jack C. Hoover of Pascagoula announces the
relocation of his office for the practice of ob-
stetrics and gynecology to the Bel Air Shopping
Center.

Don E. Killelea of Natchez was guest speaker
at a recent meeting of American Legion Post
No. 4. He spoke on care of mentally retarded
children. Dr. Killelea also appeared on the pro-
gram of the Annual Assembly of the Louisiana
Academy of General Practice in New Orleans.

Leroy B. Lamm, director of the Gulfport-Bi-
loxi VA Center, has been named director of the
Veterans Administration’s 10-state Southeastern
Medical Region.

Lynda G. Lee of Jackson and UMC was guest
speaker at the October meeting of the Central
Mississippi Chapter of Mississippi Medical As-
sistants. Her topic was medical genetics.

John B. Levens, Jr., of Bay St. Louis has been
elected chief of staff of Hancock General Hos-
pital. Other new officers are: M. L. Dodson, vice

chief of staff, and John Rutherford, III, sec-
retary-treasurer.

J. Hampton Miller, formerly of Jackson, an-
nounces the opening of his office at 2142 Com-
merce Street, Grenada, for the practice of ob-
stetrics and gynecology.

Floy Jack Moore of Jackson, professor and di-
rector of the UMC television project, has been
appointed representative to the Scientific Ex-
hibit by the Section on Psychiatry and Neurolo-
gy of the American Medical Association. In this
capacity, he will coordinate all applications for
scientific exhibits from the specialty field for
AMA annual and clinical conventions.

William H. Parker of Heidelberg was installed
as president of the Mississippi Academy of Gen-
eral Practice at the annual meeting in Biloxi.
James Stephens of Magee was named president-
elect.

S. Ray Pate of Jackson has been certified by
and is a Diplomate of the American Board of
Psychiatry and Neurology.

Bernard S. Patrick of Jackson and UMC at-
tended an October brain tumor symposium in
Columbus, Ohio.

Donald M. Sherline of Jackson and UMC par-
ticipated in the District Four regional annual
conference of the American College of Obste-
tricians and Gynecologists in Charleston, S. C.
His paper was entitled “Methods of Relieving
Pain During Delivery,” and he also spoke on
“The Choice of Anesthesia for Obstetric and

Medical Complications.”

Virginia Small of Greenville has been named
a Greenville Woman of Achievement during
Business and Professional Women’s Week.

C. D. Taylor, Jr., of Pass Christian and chair-
man of the Legislative Council of the state
medical association, spoke on the physician’s
place in politics to the Gulfport Medical Aux-
iliary recently.

Walter Taylor of Clarksdale was guest speak-
er at the District Four meeting of the Mississip-
pi Heart Association in Sumner. He discussed
high blood pressure.

Dan R. Thornton, Jr., of Meridian attended
the District Seven American College of Obste-
tricians and Gynecologists meeting in Mexico
City. Dr. Thornton completed a five-year term
as the section chairman for Mississippi and was
elected treasurer of District Seven.

654

JOURNAL MSMA

Ancel C. Tipton, Robert D. Currier, and Ar-
min F. Haerer, all of Jackson and UMC’s Di-
vision of Neurology, participated in a fall con-
ference on epilepsy at the University of South-
ern Mississippi.

Henry B. Tyler of Jackson was guest speaker
at a recent Indianola Rotary Club meeting. He
spoke on the latest techniques in cardiovascular
surgery.

David Van Landingham of Jackson was guest
speaker at a recent Mississippi Women’s Cabinet
on Public Affairs meeting. Dr. Van Landingham
discussed his family’s trip to Gaza, Israel, where
they spent their vacation helping at the Baptist
Hospital.

James C. Waites of Laurel has been elected to
a three-year term on the Laurel Chamber of
Commerce’s Board of Directors.

L. D. Webb of Calhoun City received the Cal-
houn City Chamber of Commerce’s first Out-
standing Citizen award for community service.
Dr. Webb is mayor of the city, and is active in
church and civic affairs as well as chief of staff
of Hillcrest Hospital.

Eugene F. Webb of Itta Bena has been elected
chief of medical staff of the Greenwood Leflore
Hospital. Other officers elected were John D.
Wofford, assistant chief of staff; and J. V.
Ferguson, Jr., secretary-treasurer. Milton T.
Person was elected to serve on the Executive
Committee.

Ray Wesson of Ocean Springs has been named
chairman of the Ocean Springs Hospital medi-
cal staff. Hugh Boyd is chairman-elect, and
Frank Schmidt is secretary-treasurer for the fis-
cal year which began Oct. 1, 1970.

Clark Williams of Vicksburg has been elected
president of the West Mississippi Medical So-
ciety. Charles Marascalco of Vicksburg is vice
president, and M. E. Hinman is secretary.

terned Knoxville General Hospital, Knoxville,
Tenn., one year; Emeritus member of MSMA and
AMA; died Oct. 22, 1970, age 70.

Hightower, Charles Counce, Sr., M.D.,
Jefferson Medical College of Philadelphia
1910; interned South Mississippi Infirmary, Mc-
Comb, Miss., 1910-1915; Emeritus member of
MSMA and AMA; Past President of South Mis-
sissippi Medical Society; died Oct. 28, 1970,
age 84.

Myers, Onnie Preston, M.D., Tulane Uni-
versity School of Medicine 1935; interned
Southern Baptist Hospital, New Orleans, La., one
year; urology residency, same, one year; Secre-
tary of Central Medical Society 1953-1955; Pres-
ident of Central Medical Society 1956-1957; died
Oct. 23, 1970, age 65.

Stallworth, William Lea, M.D., Tulane
University School of Medicine 1925; in-
terned Touro Infirmary, New Orleans, La., one
year; died Oct. 2, 1970, age 70.

Abraham, Ralph Ellis, Meridian. Born Meridi-
an, Miss., June 22, 1940; M.D. University of
Mississippi School of Medicine, Jackson, Miss.,
1965; interned Parkland Memorial Hospital,
Dallas, Tex., one year; surgery residency, Uni-
versity Medical Center, Jackson, Miss., July 1,
1966-June 30, 1970; elected Oct. 6, 1970 by East
Mississippi Medical Society.

Cannon, Charles Neil, Philadelphia. Born Mc-
Donald, Miss., June 12, 1924; M.D. University
of Mississippi School of Medicine, Jackson,
Miss., 1961; interned Duval County Medical
Center, Jacksonville, Fla., one year; surgery res-
idency, same, July 1, 1962-June 30, 1964; elected
Oct. 6, 1970 by East Mississippi Medical Society.

Cowart, Hiram Benjamin, M.D., Memphis
Hospital Medical College 1912; died Sept. 30,
1970, age 88.

Eberhard, John Jacob, M.D., University
of Tennessee College of Medicine 1931; in-

Dowdy, Billy Gene, Greenville. Born Hayti,
Mo., Nov. 9, 1938. M.D. University of Tennes-
see College of Medicine, Memphis, Tenn., 1964;
interned John Gaston Hospital, Memphis,
Tenn., one year; radiology residency, Methodist
Hospital, Memphis, Tenn., August 8, 1965-Au-
gust 7, 1970; elected Oct. 14, 1970 by Delta Med-
ical Society.

Hurst, Marion Fieldon, Meridian. Born Hen-
derson, Tenn., Oct. 14, 1938. M.D. University of
Tennessee College of Medicine, Memphis,

DECEMBER 1970

655

NEW MEMBERS / Continued

Term., 1963; interned Pensacola Educational
Program, Pensacola, Fla., one year; radiology
residency, Ohio State University July 1, 1965-
June 30, 1968; elected Oct. 6, 1970 by East Mis-
sissippi Medical Society.

Little, Thomas Dale, Meridian. Born Meridi-
an, Miss., June 16, 1936. M.D. University of
Mississippi School of Medicine, Jackson, Miss.,
1962; interned Cincinnati General Hospital,
Cincinnati, Ohio, one year; orthopedic surgery
residency, Georgia Baptist Hospital, Atlanta,
Ga., July 1, 1966-July 1, 1967 and January, 1968-
January 1970; residency, Scottish Rite Crippled
Children Hospital, Decatur, Ga. July, 1967-Jan-
uary, 1968 and January, 1970 to July, 1970;
elected Oct. 6, 1970, by East Mississippi Medical
Society.

Wood, William Martin, Meridian. Born Pitts-
boro. Miss., Nov. 8, 1924. M.D. University of
Tennessee School of Medicine 1946; interned
Southern Baptist Hospital, New Orleans, La.,
one year; neuropsychiatry residence, V. A. Hos-
pital, Gulfport, Miss., March 1, 1965 to Novem-
ber 27, 1965; psychiatry residency, V. A. Hos-
pital, Gulfport, Miss., January 14, 1966 to May
31, 1970; elected Oct. 6, 1970, by East Mississip-
pi Medical Society.

Lilly Discontinues
Manufacturing C-Quens

Eli Lilly and Company has announced that
it has decided to discontinue manufacturing its
oral contraceptive product C-Quens® and that
it is advising the nation’s physicians to transfer
their patients using C-Quens to other means of
fertility control in an orderly manner.

The company emphasized that there is no
cause for patient alarm. Women taking C-Quens
should continue until advised by their physi-
cians on a change.

The reason for the action is that continuing,
long-range studies have disclosed breast nodules
in some beagles that had been given 10 and 25
times the human dose of the components of
C-Quens. These nodules, none of which were
malignant, resemble those that often occur in
old female beagles and that are generally ac-
cepted to be benign.

The company emphasizes that these observa-
tions in dogs cannot be transposed directly to

human beings and that there is no evidence
known to the company of any increase in the
frequency of breast tumors in women using
C-Quens.

The same kind of long-range studies in other
laboratory animals — mice, rats, and monkeys —
and eight years of clinical investigations in
women support the safety of the drug.

Natchez School Offers
Med Self-Help Course

Because of the large number of machines in
use daily, Vocational-Technical School in Natch-
ez is offering a “Medical Self-Help” course.

Though injuries from the machines are infre-
quent, Director Richard Fallin and others on
the school staff felt the program was necessary.

Instructors for the 11-lesson course are: Juli-
an White, Adams County Civil Defense Board;
Mrs. Lee Newman, Jefferson Davis Hospital;
Mrs. Yvonne Bertolet, Mrs. Betsy Wright, and
Miss Joan Ainsworth, University of Southern
Mississippi Resident Center Nurses Training;
Ed Patton and Lt. Louis Gonnellini, Natchez
Fire Department.

Purpose of the course is to provide knowledge
and some skills in treating injuries and caring
for the sick.

The “Medical Self-Help” training program
is a cooperative effort of the Office of Civil De-
fense, U. S. Public Health Service, and the
Council on National Security of the American
Medical Association.

The use of “Medical Self-Help” techniques
assumes that a physician or nurse may not be
available for a relatively long period of time.
First aid is based on professional care being
soon available, in contrast.

The skills that the students learn, therefore,
are to be applied under emergency conditions
only. To aid in acquiring these skills, the stu-
dents will have practice sessions following most
of the lessons.

The 11 classes are divided into lessons on ra-
dioactive fallout and shelter; healthful living
in emergencies; artificial respiration; bleeding
and bandaging; fractures and splinting; trans-
portation of the injured; burns; shock, nursing
care of the sick and injured.

“The training learned at the Vocational-Tech-
nical School will enable students to care for
themselves and others during school hours as
well as away from school,” Fallin commented.

656

JOURNAL MSMA

MSMA Membership Opened to UMC
Upperclassmen, Will Have New Society

Third and fourth year students at the Uni-
versity of Mississippi School of Medicine will
soon hold membership in the state medical asso-
ciation. A special committee of the Board of
Trustees is working on organization with class
officers and student representatives.

Action to authorize a degree of membership
for medical students was approved by the House
of Delegates at the 102nd Annual Session last
May, according to Dr. Paul B. Brumby of Lex-
ington, president of the association, and Dr.
Mai S. Riddell, Jr., of Winona, chairman of the
Board.

Members of the special committee working
with the students are Drs. M. Beckett Howorth,
Jr., of Oxford, chairman, Robert E. Blount of
Jackson, and W. E. Moak of Richton. Dr.

President Paul B. Brumby, left, and Dr. Robert E.
Blount, UMC dean, right, discuss medical student
membership with Don Blackwood, UMC student
body president.

Howorth is an association officer. Dr. Blount is
acting dean and director of the University Med-
ical Center, and Dr. Moak is a member of the
Board of Trustees.

Student leaders representing upperclassmen
are Don Blackwood of Jackson, student body
president; Baxter Irby, Jr., of Grenada, presi-

Student class officers confer with Dr. M. Beckett
Howorth, Jr., of Oxford. From the left, Paul Welch,
Dr. Howorth, Baxter Irby, Jr., and David Suttle.

dent of the senior class; David Suttle of Jack-
son, vice president of the senior class; and Paul
Welch of Laurel, vice president of the student
body. Other class officers are serving on commit-
tees.

The action of the House of Delegates grew
out of Resolution No. 8 at the May 1970 annual
session. The resolution provides for a degree of
dues-free student membership with a special
component society for the group at UMC. The
new unit will be provisionally chartered as the
University Medical Society.

The juniors and seniors will conduct their
own society affairs, including election of dele-
gates to the annual session. The House action
permits first and second year students to partici-
pate in SAMA, the Student American Medical
Association chapter at UMC.

DECEMBER 1970

657

ORGANIZATION / Continued

Student membership in state medical associa-
tions has been urged by AMA. Four state associ-
ations have created the new degree: Colorado
and Kansas have chartered student societies
along the lines contemplated in the Mississippi
action, while Indiana and Pennsylvania have
opened general voting membership to the stu-
dents.

Association spokesmen said that student mem-
bership among state associations is growing, and
it is anticipated that more than 25 states will im-
plement a degree of voting membership during
1971.

Meridian Doctors Meet
With Bar Association

Medical malpractice litigation and screening
panels were main topics of discussion at the ini-
tial joint meeting of Lauderdale County phy-
sicians and the Lauderdale County Bar Associa-
tion in Meridian recently.

Key participants were Drs. Frank H. Tucker,
Jr., and Thomas Little and lawyers Walter
Eppes and Gerald Adams.

Dr. Tucker led the program with a presenta-
tion on res ipsa loquitur, followed by discus-
sion of the topic.

Those present discussed the Arizona county
committee of doctors and lawyers which more
or less arbitrates medical malpractice suits and
determines whether suits have merit.

It was decided to form a similar screening
committee in Lauderdale County. Three physi-
cians were appointed to the committee: Drs.
George Arrington, Joe Covington, and Billy Gil-
lespie.

George Warner, chairman of the Lauderdale
County Bar, appointed Eppes as representative
of the defense lawyers and Adams as represent-
ative of the plaintiff lawyers.

The newly-formed committee was instructed
to write the Arizona committee for guidelines
in organization and activities.

In other program highlights, Eppes discussed
the state statute on privileged communication
and workmen’s compensation. Dr. Little com-
pared Mississippi malpractice rates to those of
surrounding states, and Adams led the final dis-
cussion about medical reports.

Dr. Reid Speaks
at Medical Center

Dr. H. Alistair Reid, senior lecturer and consul-
tant physician, Liverpool School of Tropical Medi-
cine, Liverpool, England, was guest speaker for Cen-
ter Assembly at the University of Mississippi Medical
Center. Dr. Reid, whose specialty is clinical tropical
medicine, stopped to speak enroute from Thailand
and Taiwan. Welcoming Dr. Reid, Dr. Thomas
Brooks, professor of preventive medicine and chair-
man of the department, is at left; Dr. Robert E.
Blount, acting director of the University Medical
Center and acting dean of the University of Missis-
sippi School of Medicine, is second right, and Dr.
Hugh Keegan, professor of preventive medicine, is
at right.

New Orleans Medical
Assembly to Meet

The 34th annual meeting of The New Or-
leans Graduate Medical Assembly will be held
March 8-11, 1971, with headquarters at The
Roosevelt Hotel.

Nineteen outstanding guest speakers will par-
ticipate and their presentations will be of inter-
est to both specialists and general practitioners.
The program will include 50 informative dis-
cussions on many topics of current medical in-
terest, in addition to a clinicopathologic confer-
ence, medical motion pictures, roundtable
luncheons, and technical exhibits. This program
is acceptable for accredited hours by the Ameri-
can Academy of General Practice.

A program of entertainment for visiting la-
dies has also been planned.

For further information, contact Secretary,
Room 1538, 1430 Tulane Avenue, New Orleans,
La. 70112.

658

JOURNAL MSMA

Book Reviews

Emergency Treatment and Management. By
Thomas Flint, Jr., M.D. and Harvey D. Cain,
M.D. 733 pages. Philadelphia: W. B. Saunders
Company, 1970. $11.50.

This volume on emergency treatment and
management has been a main standby for phy-
sicians doing emergency work of any kind since
its first publication in 1954. It contains a most
conscientious review of all possible situations
encountered by emergency personnel. This is its
fourth edition and I believe it to be its best.

A special section is devoted to acute poisoning
which includes a brief description of all types
of poisons one might encounter, their antidotes,
and treatments. This section is easy to read and
the poison problem with which one is confront-
ed can be quickly located.

It would be impossible to mention all of the
areas this text covers, but I was very pleased
with their writeup on tetanus and a proper im-
munization program. The indications for the
use of tetanus toxoid and human tetanus im-
mune globulin have been somewhat confusing
in the past several years and this section was well
done.

In addition to active emergency care, a sec-
tion is provided on legal problems in emergency
care which includes responsibilities of physi-
cians in emergency cases, testimony in court, ob-
ligation of a physician as a witness, etc. All phy-
sicians in this type of work are coming more
and more into contact with legal problems and
this should prove most helpful to them. This
again proves to be a valuable compilation for
those doing emergency room care. It is recom-
mended that it be available in all emergency
room libraries.

R. J. Field, Jr., M.D.

At Your Own Risk: The Case Against Chiro-
practic. By Ralph Lee Smith. 167 pages. New
York: Trident Press, 1969. $4.95. Paperback $.95.

In this concise, easily read book, the author,
an experienced medical journalist, presents the
story of chiropractic.

Mr. Smith gives his purpose as “to set forth
what a chiropractor is, what he believes, and
what he does.” The author covers these topics
thoroughly beginning with the invention of
chiropractic by an Iowa grocer, D. D. Palmer in
1886.

The book appears to be factual. The author’s
conclusions came from his own experiences wilh
chiropractors and results of U. S. government
(HEW) studies.

Especially interesting were the chapters on
chiropractic use of x-rays and the lack of train-
ing in basic science and diagnostic skills found
in graduates of schools of chiropractic.

In the chapter on gadgeteers, Mr. Lee goes in-
to detail about the expensive gadgets chiroprac-
tors buy and use. Many have been confiscated by
government officials as frauds They actually
have no therapeutic function, he points out.

The work is attractively presented by the pub-
lisher, and is highly recommended to all physi-
cians who must tell their patients the true facts
about the cult, as well as to the lay public who
must keep informed in order to protect them-
selves.

Nola P. Gibson

ACS Inducts 19
State Physicians

Nineteen Mississippi physicians were among
1,551 surgeons inducted as new Fellows in cap-
and-gown ceremonies during the annual five-day
clinical congress of the American College of
Surgeons.

New members from Jackson are Drs. Richard

DECEMBER 1970

659

ORGANIZATION / Continued

C. Boronow, Carlos M. Chavez, Wafford H. Mer-
rell, Jr., Bernard S. Patrick, Robert R. Smith,
and Henry B. Tyler.

Other Mississippi initiates are Drs. Jerry R.
Adkins of Biloxi, Richard L. Colson of Gulf-
port, Ernest J. Holder of Laurel, John E. Lind-
ley and L. Vaughan Rush, Jr. of Meridian,
Clyde H. Gunn, Jr., of Moss Point, Harvey C.
Sanders of Mound Bayou, H. Van Craig and
John R. Young, Jr., of Natchez, Perry J. Hocka-
day of Pascagoula, Robert D. Kirk, Jr., of Tu-
pelo, and W. Briggs Hopson, Jr. of Vicksburg.

Lt. Col. Morris A. Schultz, USAF MC, of
Keesler Air Force Base was also inducted.

Fellowship is awarded to those surgeons who
fulfill comprehensive requirements of accept-
able medical education and advanced training
of surgery, and who give evidence of good mor-
al character and ethical practice.

Med Technologists Get
Postgraduate Training

Medical technologists in south Mississippi will
receive extra training in four special sessions at
the University of Southern Mississippi, which
began Nov. 4, and will continue through Jan-
uary.

A test project which may be offered in other
parts of the state, the refresher series was re-
quested by the Mississippi State Society of Medi-
cal Technologists. It is part of the Mississippi
Postgraduate Institute in the Medical Sciences,
which is supported by the Mississippi Regional
Medical Program. The University Medical Cen-
ter and Mississippi State Medical Association
were coapplicants for this project in 1969.

Each session will emphasize a different aspect
of practical medical technology. Instructors will
be registered medical technologists from the
University of Mississippi Medical Center, Mis-
sissippi Baptist Hospital, Mississippi State Hos-
pital at Whitfield and Coahoma County Hos-
pital.

Late afternoon classes, two in November and
two in January, allow participants to work in
their respective laboratories a half-day, attend
the course, and return home at a reasonable
hour.

Miss Baptist Hospital
Elects 1971 Officers

Dr. Noel C. Womack, Jr., chief of the medi-
cal staff of Mississippi Baptist Hospital in Jack-
son, has announced medical staff officers who
will begin one-year terms Jan. 1, 1971. Dr. A. L.
Meena is incoming chief of staff and Dr. R. P.
Henderson is president-elect.

Dr. H. C. Ethridge will be vice-president, and
Dr. J. O. Manning will serve as secretary of the
staff in 197 1 .

Chiefs and assistant chiefs of the medical sec-
tions for 1971 are: surgery. Dr. L. R. Hodges,
chief, and Dr. Louis A. Farber, assistant chief;
medicine, Dr. Perrin L. Berry, chief, and Dr.
G. B. Shaw, assistant chief; pediatrics, Dr. Wil-
fred Q. Cole, chief, and Dr. Cecil G. Jenkins, as-
sistant chief;

Also, obstetrics-gynecology, Dr. Henry H.
Webb, chief, and Dr. Charles M. Head, assistant
chief; psychiatry, Dr. Bruce M. Sutton, chief,
and Dr. H. A. Kroeze, assistant chief; and gen-
eral practice, Dr. Charles N. Wright, chief, and
Dr. J. P. Buckley, Jr., assistant chief.

All newly-elected officers are from Jackson.

Mental Health
Facilities Are Studied

In the growing movement toward community-
based care of the mentally ill, new relationships
are developing between community mental
health centers and state mental hospitals.

These relationships will be studied under a
$73,069 contract announced by Dr. Bertram S.
Brown, director, National Institute of Mental
Health.

The award to Socio-Technical Systems Associ-
ates, Boston, is part of NIMH’s continuing ap-
praisal of the national community mental
health centers program.

“The analysis will seek to determine what
working arrangements exist between centers and
mental hospitals, and how these relationships
affect the quality of services available to pa-
tients,” Dr. Brown said.

Some community mental health centers and
state mental hospitals are formal affiliates, while
others have developed informal working ar-
rangements. The researchers are to find out what
political, administrative, and fiscal factors oper-
ate in each type of relationship, and what im-
plications these factors have for the patient.

660

JOURNAL MSMA

Comprehensive information about coopera-
tion between state hospitals and mental health
centers will be gathered from professional lit-
erature, site visit reports, grant applications,
state plans, and other sources. Investigators will
then survey all centers which have been in op-
eration for at least six months.

Based on the information obtained, the rela-
tionships will be categorized into types, and a
small sample of facilities within each category
will receive concentrated attention.

Health Care Leaders
Initiate Liaison

Continuing, high level liaison between the
state hospital and medical associations has been
initiated to strengthen mutual goals. This was
the joint announcement of Lowery A. Woodall
of Hattiesburg, president of the Mississippi
Hospital Association, and Dr. Paul B. Brumby
of Lexington, medical association president.

The health care organization leaders said that
the first of a series of meetings has been con-

ducted “where we talked of almost every associ-
ation activity with complete candor.” They said
that the conferences were also attended by the
two chief executives of the associations, Charles
W. Flynn of MHA and Rowland B. Kennedy
of MSMA.

Mr. Woodall, who is executive director of the
Forrest County Hospital, said that “we discov-
ered more mutual goals than we imagined, and
we recognized fully that hospitals and physi-
cians have a large community of common inter-
est in health and medical legislation.”

Dr. Brumby agreed, adding that “our associa-
tions, working together, can achieve new objec-
tives in serving the patient, which is the only
reason for our respective existences.”

Also agreed at the initial presidential confer-
ence was a plan for interorganization informa-
tion exchange, including observers from one as-
sociation to selected committee meetings of the
other on an exchange basis.

Both Mr. Woodall and Dr. Brumby said that
“a major effort will be made to seek parallels in
legislative objectives during the 1971 Regular
Session.” Both leaders said that further meet-
ings are planned.

Lowery A. Woodall, left, president of the Missis- Brumby, MSMA president, at the first liaison meet-
sippi Hospital Association, confers with Dr. Paul B. ing of the health care organization leaders.

DECEMBER 1970

66 1

ORGANIZATION / Continued

Census Information
Is Made Available

Information from the 1970 U. S. census use-
ful in mental health planning will soon be
made available to the states by the National In-
stitute of Mental Health.

Using a system developed under a contract
with the General Analytics Corporation of Be-
thesda, Md., the NIMH will be able to draw up
profiles of state-designated mental health ser-
vice, or “catchment,” areas as a service to the
states.

The profiles will be made by using Bureau of
the Census statistics on population, socio-eco-
nomic status, ethnic composition, household
composition, and family structure, style of life,
housing conditions, and other factors.

States requesting the profiles can, in turn,
make the information available to community
mental health centers, the planners of new cen-
ters, and other interested parties.

The states have already received from NIMH
a prototype catchment area description for
Dane County, Wise., based on 1968 census pre-
test data, to help them plan for usage of the
1970 statistics.

The profiles can be provided to the states in
a variety of forms, including computer tapes
and printed reports. Some of the materials will
be free of charge, and others available at cost.

Questions about the profiles may be addressed
to Dr. Charles Windle, Chief, Program Analysis
and Evaluation Section, Division of Mental
Health Service Programs, National Institute of
Mental Health, 5454 Wisconsin Avenue, Chevy
Chase, Md. 20015.

In a related service, the National Clearing-
house for Mental Health Information will of-
fer researchers an experimental data retrieval
service to answer questions involving catchment
areas of more than one state. Requests for in-
formation retrieval can be addressed to Dr. Jon
K. Meyer, Chief, National Clearinghouse for
Mental Health Information, 5454 Wisconsin
Avenue (WT), Chevy Chase, Md. 20015.

250 Students Attend
Pre-Med Day

Nearly 250 students from some 23 senior and
junior colleges and universities throughout the state
came to the University of Mississippi Medical Center
for a view of medicine in action in October. Surgery
resident Dr. Robert A. Smith, right , of Heidelberg
explains a heart assist device to, from left, Miss
Pat Callicutt, pre-med advisor Glenn Bennett, Miss
Patty Hardon, all of Northeast Junior College, and
sophomore medical student Janies Balaski of Pic-
ayune.

Drs. Eisler and Ratliff
Join UMC Faculty

Two new faculty members, Dr. Richard M.
Eisler and Dr. Jack L. Ratliff, have joined the
University of Mississippi School of Medicine
teaching staff.

Dr. Eisler, who assumed his post in Novem-
ber, is assistant professor of psychiatry (psy-
chology). He earned B.A. and M.A. degrees
from Hofstra University and the Ph.D. degree
from the State University of New York. Prior
to his Mississippi appointment, Dr. Eisler was
clinical psychologist, Crisis Intervention Service,
Fort Logan Mental Health Center, Denver, Col-
orado.

Dr. Ratliff, surgery instructor and fifth-year
thoracic surgery resident, received his M.D. de-
gree from the University of Mississippi School
of Medicine. His faculty position was effective
in September.

662

JOURNAL MSM A

SUBJECT INDEX

The letters used to explain in which department the
matter indexed appears are as follows: "E,” Editorial;
"N,” News; "L,” Letters to the Editor; the asterisk (*)
indicates an original article in the JOURNAL, and the
author’s name follows the entry in brackets. "Deaths,”

A

"Personals,” and "New Members” are indexed under
the letters "D,” "P,” and "M” respectively.

Matter pertaining to MSMA is indexed under "Mis-
sissippi State Medical Association.” For the author in-
dex see page 671.

Abortion

the next 90 days, decision on [Ken-
nedy] 443-E

and the law [Kennedy] 335-E
Abraham, W. H., Jr.
installed as Fellow of American Col-
lege of Obstetricians and Gyne-
cologists, 143-N

Addie McBryde Memorial Rehabili-
tation Center for the Blind
construction begun on east wing of
UMC, 529-N
Additives

Congress criticizes HEW's handling
of cyclamate issue [Kennedy]
447-E

HEW and FDA, need to realign per-
spectives [Kennedy] 71-E
Ainsworth, Temple
named AUA president-elect, 405-N
Alcohol

writers have tendency to be alco-
holics [Kennedy] 445-E
Alcoholic Hepatitis
review of 32 cases [McKell and
Mora] *477

American Academy of Allergy

announces postgraduate course, 43-
N

American Academy of General
Practice

new project in medical communica-
tions, 619-N

takes new name, American Acade-
my of Family Physicians, 623-N
American Academy of Ophthalmol-
ogy and Otolaryngology
holds 75th annual session in Las
Vegas, 571-N

American Academy of Orthopaedic
Surgeons

publishes book on sports medicine,
619-N

American Board of Family Practice
gives second exam. 457-N
American Academy of Pediatrics
slates heart disease course, 608-N
American College of Cardiology
schedules 19th annual scientific ses-
sion, 45-N

grants fellowship to Dr. James D.
Hardy, 304-N

American College of Chest Physi-
cians

southern chapter announces annual
session. 576-N

announces 1971 Richman Essay
Contest, 617-N

American College of Obstetricians
and Gynecologists

installs Drs. Webb and Abraham as
Fellows, 143-N

installs Drs. Hull and Henderson as
Fellows, 302-N

American College of Physicians
plans gastroenterology course, 50-N
sponsors meet for Mississippi and
Louisiana internists, 85-N
sets April course on physiology.
125-N

presents internal medicine course,
522-N

sponsors 5-day postgraduate course,
526-N

plans kidney disease course, 527-N
discusses health care issues, 530-N
slates genetics course. 568-N
sponsors neurology course, 576-N
holds scientific meeting in Atlanta,
614-N

American College of Surgeons

56th clinical congress to meet,
301-N

leadership in cancer programs [Ken-
nedy] 507-E

American Council of Otolaryngol-
ogy

opens headquarters, 137-N
inducts 19 state physicians, 659-N
American EEG Society
plans 1970 meeting, 146-N
sets continuation course, 198-N
American Heart Association
meeting features arteriosclerosis,
92-N

meeting reports development of ar-
tificial placentation system, 96-N
announces deadline for grants-in-aid.

571- N

plans 43rd annual scientific session.
568-N

American Medical Association
announces Sheen Award deadline,
128-N

Committee on Medicine and Reli-
gion and MSMA committee [Ken-
nedy] 193-E

establishes specialty department,
126-N

1970-71 AMA-ERF campaign set.

572- N

inside story on membership [Ken-
nedy] 1 19-E

Judicial Council plans ethics con-
gress, 404-N

Medicredit: AMA's care delivery

system [Kennedy] 69-E
president-elect is state native. 456-N
slates occupational health congress,
450-N

sponsors medical aspects of sports
meet, 624-N
staff reorganizes, 452-N

American Pharmaceutical Associa-
tion

seeks repeal of antisubstitution laws
[Kennedy] 561-E
American Psychiatric Association
salutes SKF remotivation project.
622-N

American Urological Association
Dr. Ainsworth is president-elect.

405-N

Amputation

in patients with peripheral vascular
disease [Warren] *581
Anencephaly

in utero, roentgen diagnosis of
[Levi] *554-RS
Anesthesia

related to maternal mortality in Mis-
sissippi [Sherline] *413
Appendectomy

data show it's safe [Kennedy]
71-E

Arrington, Lamar

retires from Blue plans board, 404-
N

Arteriosclerosis

studied at AHA annual meeting.
92-N

task force plans for a 10-year re-
search assault, 626-N

Artificial Limbs

Israeli develops artificial arm, 47-N
Arts Festival, Mississippi
involves doctors' wives, 134-N
Aspirin

may be prescription drug [Kenne-
dy] 394-E

Auxiliary to MSMA
plans 1970-71 AMA-ERF campaign.
456-N

Aycock, W. J.

Robins Award winner looks back
over 51 years of practice. 504

B

Barnett, William O.
named MAMA physician of the
year, 362-N

Blood and Blood Banking

association holds annual meeting.
86-N

Blount, Robert E.

named UMC acting director and
dean. 620-N
Blue Cross-Blue Shield
promotes Max Gilliland, 139-N
Dr. Arrington retired from board.
404-N

Book Reviews and Books Received
Adams, John P.: Current Practices
in Orthopaedic Surgery [Thomp-
son] 199

American Academy of Orthopaedic
Surgeons: Symposium on Sports
Medicine [Rush] 35

DECEMBER 1970

663

Brainerd, H., Krupp, M. A., Chat-
ton, M. J., and Margen, S.: Cur-
rent Diagnosis and Treatment
[Dill] 282, 613

Daniel, W. A., Jr.: The Adolescent
Patient, 518

Duke-Elder, Sir Stewart: The Prac-
tice of Refraction, Ed. 8 [Blount |

35, 281

Egan, Donald F.: Fundamentals of
Inhalation Therapy [Campbelll

36, 341

Ellis, Philip P., and Smith, Donn
L.: Handbook of Ocular Thera-
peutics and Pharmacology [Rog-
ers) 36. 341

Flint, Thomas, Jr., and Cain, Har-
vey D.: Emergency Treatment

and Management, Ed. 4 [Field]
518, 659

Gaisford. John C.: Symposium on
Cancer of the Head and Neck —
Total Treatment and Reconstruc-
tive Rehabilitation [Shands] 282,
453

Georgiade, Nicholas G.: Plastic and
Maxillofacial Trauma Symposium
[Harthcock] 128

Hepner. James O., Boyer, John M.,
and Westerhaus, Carl L.: Person-
nel Administration and Labor Re-
lations in Health Care Facilities
[Clover] 282, 453

Jaffe, Norman S.: The Vitreous in
Clinical Ophthalmology [Buck-
ley] 282, 573

Kirklin. John W., and Karp, Rob-
ert B.: The Tetralogy of Fallot
From a Surgical Viewpoint, 518
McLennan, Charles E. : Synopsis of
Obstetrics, Ed. 8, 282
Moore, Condict: Synopsis of Clin-
ical Cancer, Ed. 2. 282
Moritz. Alan R.. and Morris.
R. Crawford: Handbook of Legal
Medicine [Kennedy] 517
Moss, Bernice R.. Southworth, War-
ren H., and Reichart, John L.:
Health Education, 36
Muehrcke. Robert C.: Acute Renal
Failure: Diagnosis and Manage-
ment [Hatten] 36, 613
Nose, Yukihiko: Manual on Arti-
ficial Organs, Vol. 1, The Arti-
ficial Kidney [Bower] 199
Reisman, Leonard E., and Matheny,
Adam P., Jr.: Genetics and Coun-
seling in Medical Practice [Jack-
son] 35

Smallpiece, Victoria: Urinary Tract
Infection in Childhood and Its
Relevance to Disease in Adult
Life [Alvis] 281

Smith, J. Ned, Jr., and Lee, Kyo R.:
Essentials of Gastroenterology
[Marascalco] 127

Smith, Philip: Arrows of Mercy, 36
Smith. Ralph L.: At Your Own
Risk: The Case Against Chiro-
practic [Gibson] 659
Solomon. Philip, and Patch, Vernon
D.: Handbook of Psychiatry

[Wilson] 282. 573

Stephenson, Hugh E., Jr.: Cardiac
Arrest and Resuscitation [Tyler]
36, 517

Stone, James H.: Crisis Fleeting
[Blount] 281. 403

Texter, E. Clinton, Jr.: Physiology
of the Gastrointestinal Tract
[Mora] 77

Urry, D. W.: Spectroscopic Ap-

proaches to Biomolecular Confor-
mation, 5 1 8

Wilson, Charles C., and Avery,
Elizabeth: Healthful School En-
vironment, 518

Winokur, G., Clayton, Paula J., and
Reich, Theodore: Manic Depres-
sive Illness [McKinley] 281, 403
Young, Clara G., and Barger, James
D.: Introduction to Medical Sci-
ence [Burman] 77
Brumby, Paul B.

Dr. Brumby Day held in Lexington,
618-N

honored by Holmes County Com-
munity Hospital Board, 528-N
Business Consulting
becomes a profession, 90-N
Butler, Frank L., Jr.
named to MSMA Committee on
Publications, 301-N
Button Power

teenage style [Kennedy] 512-E
C

Cancer: See Neoplasms
program of American College of
Surgeons [Kennedy] 507-E
cancer quiz, 17, 133
genetic aspects in humans [Jackson]
*365

Carcincma

management of early invasive car-
cinoma of the cervix [Hickman
and Gibson] *253

CARE-SOM

new dimensions in emergency medi-
cal rescue services [Shell et al]
*257

Cardiology

medical textbook published, 84-N
pacemaker management of heart
block [Bowlin] *309
course offers teacher-training, 457-N
Cardiovascular Disease
idiopathic hypertrophic subaortic
stenosis [Hatten] *106
Cardioversion

direct-current with Diazepam as
sedative agent [Rosenblatt and
Nettles] *57
Carter, Robert E.

resigns as UMC dean and director,
527-N

honored at UMC reception, 617-N
CBS

produces documentaries jaundiced
against medicine [Kennedy] 336-
E

Census

information is available, 662-N
Central Medical Society
elects new officers, 98-N

Cervix

early invasive carcinoma of [Hick-
man and Gibson] *253
Chemoprophylaxis
for prevention of tuberculosis in
Mississippi [Reid | *485
Chicago Medical Society
sets two postgraduate courses, 622-
N

Chiropractic

Sen. Eastland sponsors bill to in-
clude services under Medicare
[Kennedy] 607-E
Clinicopathological Conference
XCVI | Brent and Schiesari-Missis-
sippi Baptist Hospital) 262
CHP, Division of

study would consolidate state agen-
cies and abolish State Board of
Health, 615-N
Contraceptives, Oral
Sen. Nelson’s hearings on pill com-
plications [Kennedy] 276-E
Coronary Care Units
UMC unit nears completion, 574-N
Coronary Disease

surgery on coronary artery course
set, 456-N

Corporations, Professional
governor signs bill into law [Ken-
nedy] 191-E
C-Quens

Lilly discontinues making, 656-N
Cyclamates

Congress criticizes HEW’s handling
of issue [Kennedy] 447-E

D

Deaths

Armstrong, G. G., Sr., 32
Cannon, Russell H., 280
Cooke, James K., 197
Cowart, H. B., 655
Cowsert, Louis E., 339
Dean, Sara R., 448
Eberhard, J. J., 655
Fox, James H., 124
Grant, Roy G., 518
Graves, Z. B., 399
Green, James C., 76
Hightower, C. C., Sr., 655
McDougal, Luther L., 76
Moore, Wallace C., Jr., 399
Myers, O. P., 655
Otken, Luther B., Sr., 32
Pitchford, Ruth D., 197
Raney, Daniel H., 32
Robertson, M. H., 280
Stallworth, W. L., 655
Suttle, Thomas C., 76
Towns, Sherrod R., 568
Trudeau, Eugene A., 339
Wingo, Oliver B., 125
Dental Care

need for more insurance coverage
[Kennedy] 510-E

Diabetes Association of Mississippi
reorganized to include lay members,
282-N
Dialysis

home training unit established at
UMC, 454-N

in cases of poisoning [Bower and
Hume] *639

664

JOURNAL MSMA

Disasters

medical response to Camille evaluat-
ed, 45-N

State Board of Health commended
for service after Hurricane Ca-
mille, 80-N
Drug Abuse

much new legislation introduced
[Kennedy] 393-E
exhibit is available, 522-N
and youth [Guernsey) *585
Drug Dependence
study published by NIMH, 81-N
Drug Industry

Rx for inflation and drug costs
[Kennedy] 509-E
Drugs

and youth [Guernsey] *595
Ole Miss develops insect sting drug,
140-N

E

Eastland. Sen. James O.
helps chiropractors [Kennedy] 607-E
Education, Medical
UAB announces 3-year M.D. pro-
gram, 620-N
Egeberg, Roger O.
calls for public, private aid, 92-N
Eisier, Richard M.
joins UMC faculty, 662-N
Emergencies

surgical, of the newborn [Miller]
*585

Emergency Department, Hospital
guidelines to increase efficiency
[Milam] *61

Emergency Rescue Service
CARE-SOM, new dimensions in
[Shell, et al] *257
Endometriosis

an unusual cause of colon obstruc-
tion [Colbert] *502
Ethics, Medical

AMA Judicial Council plans 3rd na-
tional congress, 404-N
changing methods and changeless
principles [Keller] *110
Exceptional Parent Magazine
new magazine for parents of chil-
dren with disabilities, 576-N

F

Family Planning

State Board of Health reports on
project, 88-N

project serves four counties, 450-N
Family Practice Specialist
medicine’s new man [Kennedy]
273-E

Field Memorial Hospital

installs modular lifeguard system,
527-N

Flying Physicians Association
meet in Canada, 409-N
Food and Drug Administration
warns against Bard Urethral Cathe-
ters, 36-N

Upjohn gains right to argue against,
42-N

Pfizer comments on recall, 78-N

G

Gastrointestinal Lesions

role of potassium therapy [Emer-
son] 321
Genetics

and inherited human cancer [Jack-
son] *365

ACP course slated for November,
568-N

Gettysburg Commission
headed by M.D., 360-N
Gilliland, Max

promoted by Blue plans, 139-N
Grimes, D. A.

named UMC hospital director, 406-
N

H

Hall, Wesley W.

AMA president-elect and state na-
tive, 456-N
Handicapped, The
AMIA supports employment of the
handicapped [Kennedy] 652-E
Hardy, James D.
awarded ACC fellowship, 304-N
Health

leaders meet in Washington, 299-N
Health Care Delivery
Jackson chamber honors health care
team [Kennedy] 26-E
Medicredit, AMA’s plan for care de-
livery [Kennedy] 69-E
Henderson, W. EL
installed as Fellow of American
College of Obstetricians and Gyn-
ecologists, 302-N
Heart Attack

studied at Alabama Medical Center,
97-N

Heart Block

pacemaker management of [Bow-
lin] *309

Heart, Booster System
unveiled by NHI. 91-N
Hematology

problems in the newborn [Pullen
and Smith] *543
Hepatitis

acute alcoholic-review of 32 cases
[McKell and Mora] *477
Hijacking

and health insurance [Kennedy]
651-E

Hill-Burton Act [Hospital Survey
and Construction Act]
durability of the program [Kenne-
dy] 446-E
Hill, Stanley A.

named delegate to AMA, 402-N

Homicide

increases in the United States [Ken-
nedy] 394-E

Hospitals

guidelines to increase efficiency of
emergency department [Milan]
*61

cost dilemma of services [Kenne-
dy] 277-E

Field Memorial gets lifeguard sys-
tem, 527-N

Hughes, Sen. Harold E.
ungrateful liberal [Kennedy] 511-
E

Hull, Calvin T.

installed as fellow of American Col-
lege of Obstetricians and Gyn-
ecologists, 302-N
Hypnosis

new seminar offered at Mississippi
State University, 449-N

I

Immunization

program now financed by State
Board of Health, 454-N
Infants, Newborn

recent advances in care of [Brann]
*327

resuscitation of (Smith and Brann)
*417

bacterial infections in [Wright and
Brann] *493

hematologic problems of [Pullen
and Smith] *543

surgical emergencies in [Miller]
*585

Infection, Bacterial
in the newborn [Wright and
Brann] *493

Instruments, Microsurgical
new line introduced, 523-N
Insurance, Health
and hijacking [Kennedy] 651-E
need for more dental care coverage
[Kennedy] 510-E

executives combat rising costs, 93-N
four faces of national health insur-
ance [Kennedy] 647-E
Insurance, Professional Liability
House Bill 407 threatens low premi-
ums [Kennedy] 118-E
Internal Revenue Service
sends cards explaining 1040. 80-N
pre-addressed labels speed returns,
128-N

early filing speeds up returns, 145-
N

International College of Surgeons

schedules 17th congress in Paris,
130-N

schedules 3rd western hemisphere
congress, 530-N

3rd western hemisphere congress to
meet in Las Vegas, 616-N
Inversion, Uterine

case report XIV of Maternal Mor-
tality Study [Nassar] *541

J

Jenkins, W. N.

honored for 50 years of service,
572-N

Joint Commission on Accreditation
of Hospitals

growing role [Kennedy] 650-E

K

Kidney

ACP sponsors course on renal dis-
eases, 527-N

Kidney, Artificial

in acute renal failure [Bower]
*317

use of in cases of poisoning [Bower
and Hume] *639

DECEMBER 1970

665

L

Lakeland Graduate Medical Assem-
bly

schedules Frontiers of Medicine
1970, 36-N
Lampton, T. D.
named RMP director, 647-N
Language

Memphis psychiatrist publishes Now
70’s Dictionary [Kennedy] 561-
E

Leathers, Waller S.

portrait donated to UMC, 622-N

Legislation

is everybody’s crisis [Kennedy]
389-E

new beefed-up MSMA program to
ask aid of all members, 569-N
punitive bill aimed at physicians
[Kennedy] 118-E
Letters to the Editor
Rubella lecture at Mississippi State
University [Ricks] 76-L
Liability

without negligence, Illinois State Su-
preme Court decision [Kennedy]
607-E

Lifeguard System

Field Memorial Hospital installs
modular system, 527-N
Eli Lilly and Company
discontinues manufacturing C-Quens,
656-N

Linton, Patrick H.

named new psychiatry chief at Ala-
bama, 132-N
Long, Lawrence W.
receives ICS award. 85-N
Lotterhos, William E.
becomes president of AAGP. 623-N
discusses new AAGP program, 619-
N

M

Magnuson, Harold J.

receives IMA Knudsen award. 292-
N

Marihuana: See also Drug Abuse
grown by Ole Miss School of Phar-
macy, 84-N

bibliography published by Ole Miss
School of Pharmacy, 621-N
Maternal Mortality
related to anesthesia in Mississippi
[Sherline] *413

case report XIV of study [Nassar]
*541

McCaskill, Luther W.
acquitted of abortion murder, 136-N
charges against dropped, 302-N
McCleave, Rev, Dr. Paul D.
appears before MSMA Committee
on Medicine and Religion and
UMC, 40-N

M. D. Anderson Hospital
plans cancer rehabilitation confer-
ence, 574-N
Measles

Rubella campaign gets good results,
43-N

Meat, Synthetic

meatless meat developed [Kenne-
dy] 193-E

Medicaid

in Mississippi: a bare bones begin-
ning [Kennedy] 23-E
Alabama qualifies Mississippi physi-
cians, 132-N

more regulations announced, 135-N
Greene County screened, 280-N
Medicare

increases hospital deductibles, 84-N
more regulations announced, 135-N
four M.D.’s indicted for fraud, 143-
N

Part 1-B [Kennedy] 275-E
Part C [Kennedy] 387-E
Medicredit: See also American Med-
ical Association

AMA’s plan for national health in-
surance [Kennedy] 69-E
Medical Care Foundations
private delivery that works [Ken-
nedy] 557-E
Medical Careers

corpsmen, new manpower tool
[Kennedy] 276-E
Medical Ethics

changing methods and changeless
principles [Keller] *110
Medical Organization: See also spe-
cific titles such as American Med-
ical Association, Mississippi State
Medical Association
medicine for the 70’s [Royals]
*374

Medical Science

changing methods and changeless
principles [Keller] *110
Medical Services

cost more today [Kennedy] 337-E
Medihc

new manpower tool [Kennedy]
276-E

Members, New
Abraham. Ralph E., 655
Barry, Esther Garcia, 568
Bennett, Kenneth R., 125
Blaylock, Darrell N., 339
Cannon, Charles N., 655
Chavez, Carlos Manuel, 76
Cockrell, Marion E., Jr., 125
Collins, Rex W., 125
Collins, Ted Zanny, 516
Day, Larry H., 339
Dowdy, B. G., 655
Durfey. A. P., Jr., 279
Ederington, John B., 125
Evers, Carl G., 399
Fulcher, Luther H., Jr., 125
Gifford, W. B„ 279
Giles, William G., 339
Goodlow, William H., Jr., 125
Gore, Edward K., 279
Hamernik, R. J., 279
Hammett, Larry J., 339
Hartness, Durward S., 339
Hickerson, Otrie B., 125
Hoover, Jack C., 339
Humphrey, Charles R., Jr., 568
Hurst, Marion F., 655
Kliesch, William F., 399
Kobs, Darcey Gus, Jr., 516
Lewis, Fredric A., 448
Little, Thomas D., 656
Lynch, W. F., Jr., 279
McFadden, J. W., 279

Miller, Richard Charles, 197

Mitchell, Larry Morris, 516

Owens, L. J., 612

Ozborn, C. A., 280

Pandey, Shanti, 568

Rester, Robert Raymond, 197

Richardson, Travis Quitman, 516

Scott, Edward G., Jr., 339

Smith, Jimmie L., 339

Speck, James W., 197

Sprabery, Archie P., 197

Vesa, Antonio Gregori, 568

Walden, Thomas B., 197

Walker, B. L„ 280

Ward, Roderick D„ Jr., 339

White, Ellison F., 197

Wilder, S. J., Jr., 280

Wood, William M., 656

Mental Health

facilities are studied, 660-N

Meridian gets center, 523-N

Meridian

physicians and lawyers meet, 658-N
Microfiche Camera
new low cost table top model. 529-
N

Mississippi Association of Medical
Assistants

Dr. Barnett named MAMA physi-
cian of the year, 362-N
Mrs. Pace named AAMA trustee,
43-N

Mississippi Baptist Hospital
elects 1970 officers, 78-N
elects 1971 officers, 660-N
Mississippi Heart Association
holds annual assembly, 291-N
breaks ground for headquarters
building, 406-N

offers CPR faculty training course,
457-N

announces 1971-72 research grants
and fellowships program, 618-N
Mississippi Hospital Association
elects officers, 455-N
meets with MSMA leaders, 661-N
Mississippi Jaycees
collect drug samples for Vietnam,
282-N

Mississippi Regional Medical Pro-
gram

awards cardiopulmonary grant, 29-N
Dr. Lampton is named director, 447-
N

expands activities, 41-N
Mississippi State Board of Health
and UMC set up neurological clin-
ics, 42-N

commended by USPHS, 80-N
crippled children's service trans-
ferred [Kennedy] 390-E
Dr. Mitchell named director of local
health services, 452-N
family planning project serving four
counties, 450-N

Greene County screened for Med-
icaid, 280-N

Hinds County children immunized
against Rubella, 362-N
Mr. Whitaker selected for study,
457-N

now finances immunization pro-
grams, 454-N

reports on family planning project,
88-N

666

JOURNAL MSMA

Rubella campaign gets good results,
43-N

sponsors radiological courses, 407-N
studies simultaneous vaccinations,
126-N

three appointed by governor, 361-N
warns about animal bites, rabies,
78-N

would be abolished in CHP (PMM)
plan, 615-N

Mississippi State Medical Associa-
tion

auxiliary plans 1970-71 AMA-ERF
campaign, 456-N

beefed-up legislative program to ask
aid of all members, 569-N
Board of Trustees — new officers,
361-N; sets 102nd Annual Session
for May 11-14, 129-N
building addition opened. 283-N
Central Medical Society — elects of-
ficers, 98-N

commended by state House of Rep-
resentatives, 282-N
Committee on Medicine and Reli-
gion— complete care of whole
man [Kennedy] 193-E; MSMA
and UMC hear AMA's Dr. Mc-
Cleave, 40-N

Constitution and By-Laws, 378
economic asset of membership
[Kennedy] 559-E

Committee on Publications — Dr.
Frank L. Butler, Jr., appointed,
301-N

governor signs professional corpora-
tions into law, 304-N
headquarters addition formal open-
ing set by Board of Trustees, 79-
N

Hill, Stanley A., is new AMA dele-
gate, 402-N

House of Delegates — handbook of
102nd Annual Session, 187; news
report on proceedings, 347-N; text
of proceedings, 427-N
102nd Annual Session — official call
and program, 163; Dr. Brumby
inaugurated president. Dr. Brown
named president-elect, 343-N
103rd Annual Session — scientific as-
sembly begins work, 358-N; sci-
entific assembly begins work and
invites exhibits, essays, 451-N
1970 Directory mailed. 86-N
membership opened to upperclass
UMC students, 657-N
new membership service to itemize
dues initiated. 519-N
newsletter gets facelifting [Kenne-
dy] 25 -E

President's Page, Royals — 'Needed
Now,’ 22; 'Best Part of the Job,’
68; 'Or Lose by Default,’ 116;
‘Continuum of Crisis,’ 190; ‘Past
and Future: The Task Ahead.’ 272
President's Page, Brumby — 'Changes
and Challenge,’ 334; 'The Mak-
ing of an M.D.,’ 386; 'Our Medi-
cal Democracy,’ 442; 'Dilemma in
Blue,’ 506; ‘Growing Pains,’ 556;
‘A Busted Play,’ 602; ‘LPN's
Fight Drug Abuse,’ 646

Robins Award, W. J. Aycock is re-
cipient, 349-N

Wiygul, Frank M., Jr., named sec-
tion officer, 143-N
Mississippi State University
announces seminar in hypnosis,
449-N

Mitchell Lectures feature Dr. Coop-
er, 39-N

Mississippi Thoracic Society
holds annual meeting, 301-N
new officers, 405-N
Mississippi Tuberculosis and Respi-
ratory Disease Association
Dr. Tate is guest speaker, 304-N
Mitchell, J. Daniel
is UM alumni president-elect, 455-
N

Mitchell, Shelby W.

named director of local health ser-
vices of State Board of Health,
452-N

Mound Park Hospital Foundation

schedules postgraduate courses, 85-
N

Myeloma

multiple or plasma cell [Blount]
*268-RS

Myocardial Infarction

Alabama sets up study centers, 97-N
emergency surgery for [Tirnmis
et al] * 101

N

Narcotics

the old admonition [Kennedy] 120-
E

National Health Insurance
four faces of [Kennedy] 647-E
Natchez Vocational-Technical
School

offers medical self-help course, 656-
N

National Institutes of Health

meets with task force on arterio-
sclerosis, 626-N

National Heart and Lung Institute

establishes specialized research cen-
ters, 626-N

works with task force on arterio-
sclerosis, 626-N
Neurological Disorders
syringomyelia in Mississippi [Tip-
ton and Haerer] *533
Newborn Care

Seminar I, Recent Advances in
[Brann] *327

Seminar II, Resuscitation of [Smith
and Brann] *417

Seminar III. Acute Bacterial Infec-
tions in [Wright and Brann] *493
Seminar IV, Newborn Hematologic
Problems [Pullen and Smith] *543
Seminar V, Surgical Emergencies in
[Miller] *585

UMC adds nursery and intensive
care unit, 530-N

New Orleans Graduate Medical As-
sembly

holds 33rd annual meeting, 88-N
sets 34th annual assembly, 658-N

NORC

4th study on health care and cost
[Kennedy] 605-E

Nursing

mandatory licensure for Mississippi
]Kennedy[ 605-E

master’s degree offered at UMC,
624-N

O

Obstetrics

and gynecology, practical uses of
steroids and gonadotropins [But-
tram et al] * 1

prevention of maternal Rh sensiti-
zation: anti-Rh immune globulin
[Wilson] *53
Ophthalmology

management of posterior segment
intraocular foreign bodies [Gold-
berg] *149

Overland Terrain Vehicles

can be dangerous [Kennedy] 73-E

P

Pace, Mrs. Thomas D., Jr.
named AAMA trustee, 43-N
Panama

Panama Limited discontinued [Ken-
nedy] 606-E
Peer Review

in Mississippi [Kennedy] 603-E
Pegram, G. Vernon, Jr.
studies sleep problems at UAB. 614-
N

Peripheral Vascular Disease
amputations in patients with [War-
ren] *581
Personals

Abide, John K., 278, 448, 513
Adkins, Jerry R., 570
Allard. George, 278
Allen, Raymond A., 570
Allison. James W., 448
Amacker. Dempsey T., 337, 611
Atwood, John G., 278
Aycock, W. J., 611
Bailey, James W., 513
Bailey, S. Lamar, 513, 570
Baird, Frank, 513
Ball, David A.. 513
Ball. Ottis G.. 278
Banahan. B. F., Jr., 449
Barnes, G. Spencer, 75, 278, 516
Barnett, Jim. 75, 513
Barnett, William O., 30
Bass, William L., Jr., 653
Batson. Blair E., 30
Beacham, A. V., 397, 448
Benefield, T. E., Jr., 612
Bennett, Kenneth R., 570
Berry, Sidney R., 516
Biles, G. Lacey, 30, 397
Blake, Tom H.. 653
Blake, Thomas M., 570
Blakey. Durward, 75
Blissard, Thomasina, 337
Blount, Robert E., 30
Bobo. Edgar E., 654
Bobo, William B., 196
Boggess, Julian E., 570
Boggs, Julian E., Jr., 338
Booth. J. E., 75
Boren, F. C., 278
Boswell, Hugh P., Jr., 513
Bouchillon, C. D., Ill, 124
Bounds, L. H., 30, 123
Bower, John D., 30

DECEMBER 1970

667

Boyd, Hugh L„ 448, 655
Bramlett, E. V., 570
Bramlett, Julian, 338
Brann, A. W., Jr., 612
Breland, A. E., Jr., 654
Brock, Ralph H., 30
Brooks, Tommy, 196
Browning. Raymond W., 30
Brumby, Paul B., 30, 123, 278
Buckley, Theresa L. R., 278, 612
Burgess, Duane C., 123, 338
Burman, R. G., 278
Bush, Eugene A., 654
Caldwell, R. E., 513
Caldwell, Robert S., 196
Caldwell, W. E., 513
Cannon, Charles N., 123, 196
Carney, P. Temple, 123, 397
Carter, David K., 513
Carter, Robert E., 30, 123, 196
Carruth, E. L„ 612
Catchings, Charles E„ 448
Caruther, S. B., 513
Cavett, James R., Jr., 513
Chase, Vernon A., 513
Chavez, Carlos M., 654
Clark, Howard D., 278
Clark, L. J., Jr., 278
Cleveland, C. Hal, 30, 338
Clippinger, D. L., 75, 513, 612
Cobb, Alton B., 30, 338, 612
Cockrell, Marion E., 123, 448
Conerly. Dawson B., Jr., 397
Conner, Douglas L., 448
Cook, Gaines L., 30
Copeland, Clyde X., Jr., 123
Cotten, Milam S., 513
Cottrell, Hugh B„ 30, 196, 570
Covington, Joe S., 123
Cox, Charles J., 338
Craig, Harris V., 448
Crawford, J. P., 75
Crawford, Walter, 30, 570
Criss, Ralph J., Jr., 397
Crosthwait, James L., 570
Crowson, William N., 448
Culpepper, J. P., Jr., 75
Currier, Robert D.. 123, 654, 655
Davis, John R., 513
Dodson, M. L., 654
Donald, Robert L., 30, 448
Doster. James T., 196, 278
Downer, John, 278
Draughn, D. H., 612
Durfey, A. P„ 278
Durfey, A. P., Jr., 278
Durfey, John R., 278
Easterley, C. E., 397
Eggerton, William E., 30
Ehrich, Melvin, 75
Ellis, Ernest E., 338
Eure, W. R„ 397
Fabian, Leonard W., 448
Ferguson, J. V., Jr., 655
Ferrington, Elizabeth, 278
Field, R. J., Jr., 612
Flechas, Enrique, 449, 612
Flowers, William M., 196
Folk, Ben P., 75
Frye, Harry C., Jr., 75, 278
Fulcher, Luther H., 278
Gabbert, Elmo P., 448
Gaddy, Ira E., Jr., 30
Gandy, Thomas H., 338, 654

Garrett, E. S., Jr., 448
Gary, William A., 196
Gates, R. F., 30
Gates, William C., 513
Gatling, Robert R., 570
Giffin, James R., 123
Gilbert, Wendell N., 75, 278
Giles, Hannelore H., 30
Gillespie, Guy T., Jr., 123, 196
Gillespie, H. Lamar, 278
Godfrey, William E„ III, 196
Grabowski, Stanislaw, 123
Green, Earl W„ 513
Green, George, 75
Green, John E., 513
Grenfell, Raymond F., 30
Guyton, Arthur C., 30
Haerer, A. F., 123, 448, 655
Hale, Carl R., 30, 196
Hardy, James D., 123
Harrington, John N., 278
Harris, Elmer J., 278
Hatten, Karl W., 123, 338, 570,
612

Hawkins, Mary E., 278
Hays, Arthur V., 338
Hays, James C., 397, 570
Hays, Martha, 123
Hedgewood, Henri M., 123
Hellems, Harper K., 30
Henderson, Robert P., 278
Hendrick, James G., 30, 448
Hendrix, James H., Jr., 279
Henneberger, George, 448
Herring, Emmett, 513
Hiatt, Warren A., 75
Hicks, G. Swink, 30
Hilbun, Ben M., 612
Hinman, M. E., 655
Hogan, Marcus, 278
Holleman, Henry, 5 1 3
Hollingshead, C. A., 338, 397
Hollingsworth, Elizabeth, 516
Hollingsworth, J. W., 448, 570
Hollis, Allen, 654
Holmes, Verner S., 124
Hoover, Jack C., 123, 654
Hopkins, Gerald, 30, 123
Horn, Paul L., Jr., 30
House, J. R., Jr., 612
Howard, Anse B., Ill, 571
Howell, John B., Jr., 338
Howell, Leroy, 76, 449
Howell, T. R„ 338
Hutchinson, Richard G., 30
lies, Jerry W., 30
Irby, Oscar W., 338
Ireland, Robert, 75
Jaquith, W. L„ 30, 338, 612
Jenkins, W. N„ 513
Jeter, Marvin H., 570
Jobe, Louis H., 397
Johnson, Ben B., 449
Johnson, Richard, 124
Jones, Edley, Sr., 124
Kaplan, Jerry, 76
Keel, Dan T., Jr., 279
Killelea, Donald E., 196, 654
Kimbrough, George T., 570
Kirk, Andy E., 76, 449
Kliesch, Nancy L., 397
Kliesch, William F., 570, 612
Knox, I. C., Jr., 338
Kuljis, Joseph, 612

Laird, Earl L., 513
Lake, Wesley W., 338
Lamb, Woodrow, 513
Lamm, Leroy B., 654
Landry, V. E., 397
Lane, Dewey H., Jr., 124, 279, 570
Lane, John T., 397
Langford, Herbert G., 30, 449
Lee, A. Eugene, 513
Lee, Mary Alice, 196
Lee, Lynda G., 654
Lee, Ray, 124
Lehmann, Louis C., 196
Levens, John B., Jr., 654
Lewis, Fred A., 278
Lewis, Henry L., Ill, 75
Lingle, Jerry, 513
Little, Gerald M., 397
Little, Thomas D., 513
Lockard, Blanche, 75
Lockwood, William R., 513, 570
Logan, James G., 338
Long, Lawrence W., 124
Long, William A., Jr., 279
Lotterhos, William E., 30, 32, 124,
196, 338, 449, 570,

Love, M. S., 279
Lowe, C. Foster, 513
Lummus, Floyd L., 279
Magee, Harold G., 449
Mann, J. E., 612
Manning, J. O., 513
Marascalco, Charles, 655
Martin, Ben F., 516
Martin, Thomas Stanley, 32
Martinolich, A. K., 30
Masterson, Chester W., 397
McDonald, Thomas J., 338
McDonnieal, S. H., Jr., 397
McDougal, L. L., 197
McFadden, John, 124
McFarland, Wesley L., 338
McKell, William M„ Jr., 397
McKinley, Robert L., Jr., 124, 338,
612

McLain, James L., 279
McRae, John M., 196
McVey, Eric A., 30
Meena, Albert L., 32
Miller, J. Hampton, 654
Mink, Paul E., 570
Mitchell, C. B., 197
Mitchell, Shelby W„ 32, 338,
Mitchell, Tom H., 278
Moore, Floy J., 654
Moore, Paul H., 397
Moore, Steven L., 32, 612
Morgan, Frank J., Jr., 513
Moynihan, Patricia, 124
Mullens, J. R., Jr., 124
Munn, William G., 32, 279
Murfee, John A., Jr., 449
Murry, Charles M., Jr., 570
Mutziger, Dudley H., 32
Naef, Richard W., 123
Nealy, Wren R., 516
Netterville, Rush, 124
Nix, J. Elmer, 516
Norman, Joe Robert, 516
Oates, J. K., Jr., 124
O’Neal, K. Ramsay, 278
Owens, Louis J., 448
Owens, W. F., Jr., 123
Packer, James M., 278

668

JOURNAL MSMA

Pandey, Shanti, 449
Parker. William H., 278, 654
Pate, S. Ray, 654
Patrick, Bernard S., 654
Pearson. Glenn T., 32
Peeler, Joe G.. Jr., 279
Pennington, V. M., 612
Person. Milton T., 655
Pharr, Max L., 338
Philpot, Van B., Jr., 338
Pickle, A. C., 197
Pittman. James A., 570
Polk, Octavius D., 123
Prescott. J. T., 124
Profilet, William B., Jr., 516
Purvis, Thomas L., Jr., 196
Puryear, Lamar, Jr., 516
Rader, Ben B., Jr., 449
Raines, D. C., Ill, 278
Raulston. William R., 278
Rayner, D. R., 612
Read, Allen M., 570
Redd, Janice, 30
Reeves. Ernest P., 197
Rester, Robert, 32, 654
Riemann. E. T., Jr., 30
Robbins. E. P„ 449
Roberts, Curtis D., 32, 124,
Robinson, R. B., 196
Rodriguez, Gaston, 30
Rose, Walter, 612

Rosenblatt, William H.. 397. 516,
570

Ross, Joe M., Jr., 30
Ross, T. E., Ill, 197, 612
Ross, Thomas G., 570
Royals. James L., 30
Rubenstein, L. A.. 612
Russell. S. C., 76, 612
Rutherford, J. D., Ill, 570, 654
Rutledge, Lewis J., 124
Samson, Roland, 32
Santina, Henry D., 516
Schmidt. E. J., 197
Schmidt. Frank. 655
Schmidt, Harry J.. Sr., 76
Schmidt. Richard C., 76
Scott, E. G., Jr., 612
Sharbrough, Richmond. 32
Shaw, Boyd, 124
Sherline. D. M., 612, 654
Simmons. Thomas H.. 570
Small. Virginia. 654
Smith. Perrin N., 513
Sneed, Ralph, 338
Steckler. David R., 570
Stephens, James, 654
Stewart. Edsel F., 516
Stockton. Wendell H., 516
Stodard. Preston R., 338
Stowers. K. B., 397
Stowers, W. K., 397
Surratt, Robert T., 124
Sutherland, Claude G., 196
Sweat, William A., 570
Tannehill, Antone W., Jr., 279
Taquino, Maurice A., 32. 397, 612
Tatum. Frank K., 76, 124,

Tatum, Fred, 123
Taylor, C. D., Jr., 197, 654
Taylor, Walter T„ 30, 338, 654
Thaggard. Lamar, 397
Thompson, J. T.. 570, 612
Thompson. Robert H., 516

Thornton, Dan R., Jr., 654
Tibbs, Robert C., II, 397
Tillman, Clifford, 338, 516
Tipton, Ancel C., 655
Todd, Norman W., 32
Tolbert, Virginia S., 338, 449
Totten, James C., Jr., 449
Treadwell, Walter, 124
Tyler, Charles C., 397
Tyler, Henry B., 612, 655
Tyrone, Nelson O., 397
Van Landingham, David J., 655
Vise, Guy T., 32
Vise, Guy T., Jr., 570
Waites, James C., 279, 449, 655
Watkins, J. W., 397
Watson, David G., 30. 32
Webb, Eugene F., 655
Webb. L. D., 516. 655
Wells, Fred, Jr., 571
Wesson, Ray L., 570, 655
White, Elbert A., Ill, 76, 124
White, W. B., 338
Wiener, Julian, 397
Williams, Charles, 654
Williams, Clark, 655
Williamson, Stoney, 571
Wilson, David B., 30, 32, 338, 516
Wilson, David T., 571
Winstead, W. B„ 516
Wiygul, Frank M.. Jr., 197
Wofford. John D., 124, 655
Womack, Noel C„ Jr., 196, 449
Wood. William L„ Jr., 76, 124
Woodbridge. Hardy B., Jr., 338, 449
Wyatt, Rhea L., 124
Yates, Andrew J., 397
Yerger, L. B., Jr., 123
Young. John R.. Jr., 279, 338
Pfizer Laboratories
comments of FDA recall, 78-N
Physical Education
new image, sports science [Kenne-
dy] 446-E
Physicians

Arts Festival involves wives, 134-N
can now incorporate in Mississippi
[Kennedy] 191-E

family practice specialist [Kenne-
dy] 273-E

four indicted for Medicare fraud,
143-N

have everything but time [Kennedv]
651-E

Pituitary

tumors, roentgen changes in the sel-
la turcica [Conley] *600

Poisoning

significance of analytical toxicology
in the treatment of [Hume and
Bower] *636

use of in cases of poisoning [Bower
and Hume] *639

Pollution

environment at stake [Kennedy]
27-E

Potassium

therapy and gastrointestinal lesions
[Emerson] *321
Project Care-Som

new dimensions in emergency med-
ical rescue services [Shell et al]
*257

R

Rabies

State Board of Health warns about,
78-N

Radiologic Seminars
Tracheoesophageal Fistula [Col-
bert] *18

Subclavian Steal Syndrome [Mc-
Cay] *66

Inferior Vena Cavography [Ball]
*114

Intravenous Cholangiography [Bar-
low] *160

Multiple Myeloma [Blount] *268
Reversible Vascular Occlusion of the
Colon [Bouchillon] *331
Ureteropelvic Junction Obstruction
[Burrow] *372

Duplications of the Renal Pelvis and
Ureter [McCay] *424
Endometriosis: An Unusual Cause
of Colon Obstruction [Colbert]
*502

Roentgen Diagnosis of Anencephaly
in Utero [Levi] *554
Roentgen Changes in the Sella Tur-
cica in Pituitary Tumors [Con-
ley] *600

Paget's Disease [McCay] *644
Ratliff, Jack L.
joins UMC faculty, 662-N
Redbook Magazine
publishes new mother’s guide, 86-N
Reid, H. Alistair speaks at UMC,
658-N

Renal Failure

artificial kidneys in the management
of [Bower] *317
Research

specialized centers established by
NHLI, 626-N

Respiratory Disease
modern concepts in treatment of in-
sufficiency [Shaw] *13
Resuscitation

of the newborn [Smith and Brann]
*417

Rh Sensitization

prevention of: anti-Rh immune glob-
ulin [Wilson] *53
Richman Essay

1971 contest announced by ACCP,
617-N

Rubella: See measles.

S

Safety

restraining devices help mother
make sure [Kennedy] 119-E
Sanders, John R.
gets Yugoslavian fellowship, 82-N
Sleep

studied by UAB scientist, 614-N

Smith, Kline and French Labora-
tories

remotivation project receives APA
award, 622-N
Smoking

new angle: invasion of privacy

[Kennedy] 117-E

DECEMBER 1970

669

Social Security Administration
self-employed M.D.’s insured for
disability, 39-N

to sue five care facilities, 139-N
St. Dominic-Jackson Memorial Hos-
pital

elects medical staff, 136-N
Stenosis

idiopathic hypertrophic subaortic
[Hatten] *106
Sterility

evaluation studies by microbiologist,
5 1 8-N

Student American Medical Associa-
tion

reactivated at UMC, 402-N

Sumner, A. F.

Mississippi Attorney General speaks
to UMC Student Assembly, 62 1 -
N

Surgery

coronary artery course set, 456-N
emergencies of the newborn [Mil-
ler] *585

for early invasive carcinoma other
cervix [Hickman and Gibson]
*253

of the thymus [Bernatz] *629
Syringomyelia

in Mississippi [Tipton and Haerer]
*533

T

Tamp-R-Tel

new packaging concept introduced
by Wyeth, 295-N
Tate, Charles F., Jr.
addresses TB-RD association, 304-
N

Taxes

bill proposed to end inheritance tax,
94-N

pre-addressed labels speed returns,
128-N

the agony and ecstasy of [Kenne-
dy] 72-E

Technicon Corporation
announces Auto Analyzer II, 131-N
Teenage Nation

profile of our children [Kennedy]
565-E

TELEMED

develops multiprocessing computer,
404-N

Thiede, Henry A.

named UMC assistant dean, 612-N

Thymus

surgery of [Bernatz] *629
Toxicology

significance of in treatment of poi-
soning [Hume and Bower] *636
Tri-State Thoracic Society
meets at Biloxi, 50-N
Tuberculosis

27 months of chemoprophylaxis
for prevention of, in Mississippi
[Reid] *485
Tumors

pituitary, roentgen changes in the
sella turcica [Conley] *600

U

University of Alabama Medical Cen-
ter

announces 3-year M.D. program,
620-N

names new psychiatry chief, 132-N
opens intensive care unit, 81-N
scientist studies sleep, 614-N
to study heart attack, 97-N
uses NIRU computer, 49-N
University of California
announces master of public health
program, 626-N

hosts postgraduate education pro-
gram, 41-N

sponsors postgraduate courses, 85-N
offers hypertension course, 82-N
presents OB-GYN seminar, 361-N
University of Illinois
plans postgraduate laryngology and
bronchoesophagology course, 612-
N

University of Mississippi School of
Medicine

adds newborn nursery and intensive
care unit, 530-N
adds five to faculty, 5 2 8-N
alumni house dedicated, 401-N
and State Board of Health set up
neurological clinics, 42-N
announces faculty changes, 616-N
announces new appointments, 50-N
Attorney Gen. Sumner speaks at
Student Assembly, 621-N
Blount, R. E., named acting direc-
tor and dean, 620-N
Carter, R. E., resigns as dean and
director, 527-N

commencement activities announced,
304-N

construction begins on blind reha-
bilitation center, 529-N
coronary care unit nears comple-
tion, 574-N

Eisler, R. M. and Ratliff, J. L., join
faculty, 662-N

establishes home dialysis unit, 454-
N

graduates 75 M.D.'s, 407-N
Grimes, D. A., named hospital ad-
ministrator, 406-N

honors Dr. and Mrs. R. E. Carter at
reception, 617-N

instituted baccalaureate degree pro-
gram for medical record librari-
ans, 526-N

Leathers’ portrait given to school,
622-N

medical alumni president-elect is Dr.

J. Dan Mitchell, 455-N
medical technologists get postgrad-
uate training, 660-N
MSMA membership opened to up-
perclassmen. 657-N
offers nurses master degree program,
624-N

Reid, H. Alistair speaks, 658-N
SAMA chapter reactivated, 402-N
Snavely Medical Library dedicated,
526-N

Thiede, Henry A., named assistant
dean, 612-N

ups faculty to 182, 450-N
ups freshman class to 95, 528-N
250 students attend Pre-Med Day,
662-N

University of Mississippi School of
Pharmacy

develops insect sting drug, 140-N
grows marihuana, 84-N
organizes pharmacy museum, 198-N
publishes marihuana index, 621-N
ups standing, 137-N
University of Southern Mississippi
student health services offer com-
prehensive program, 37-N
Upjohn Company, The
court gives right to argue

V

Vascular Disease

peripheral, amputations in patients
with [Warren] *581
Vietnam Returnees
acute illness among [Blount] *8

W

Webb, Henry H.

installed as Fellow of American
College of Obstetricians and Gyn-
ecologists, 143-N
West Mississippi Medical Society
elects officers, 146-N
Williams, M. Ney

heads Gettysburg Commission, 360-
N

Whitaker, Harold H.

selected for USPHS study, 457-N
Wiygul, Frank M., Jr.
named MSMA section officer, 143-
N

Woman’s Auxiliary to MSMA
plans 1970-71 AMA-ERF campaign,
456-N

Wood, Chad and Judy
Mississippian's children graduate
from UT, 86-N
Wong, Vernon G.

appointed NEI clinical director, 624-
N

Wyeth Laboratories

designs Ovral 3-month package,
574-N

development reported at AHA meet-
ing, 96-N

films win awards at 12th annual
American Film Festival, 623-N
introduces new packaging concept,
295-N

president is foundation chairman,
409-N

Y

Yale Medical School
gets $2 million grant, 90-N
Yellow Pages

consumer study shows active mar-
ket use for pharmacies, 524-N
Youth

and drugs [Guernsey] *595

670

JOURNAL MSMA

AUTHOR INDEX

The letters used to explain in which department the Page; "RS,” Radiologic Seminar. The asterisk (*) indi-
matter indexed appears are as follows: "E,” Editorial; cates an original article in the JOURNAL.

"N,” News; "L,” Letters to the Editor; "PP,” President’s

A

Alvis, J. L., 281-BR

B

Ball O. G., * 1 14-RS
Barlow, J. B., *160-RS
Bernatz, P. E., *629
Blount, J. G., *268-RS
Blount, R. L., 281-BR
Blount, R. E., *8, 403-BR
Bouchillon, C. D.. *331-RS
Bower, J. D., 199-BR. *317, *636,
*639

Bowlin, J. W., *309
Brann, A. W„ Jr., *327, *417, *493
Brent, A. E.. 262-CPC
Brumby, P. B„ 334-PP. 386-PP,
442-PP, 506-PP. 556-PP. 602-PP,
646-PP

Buckley, T. L. R.. 573-BR
Burman, R. G., 77-BR
Burrow, N. W., *372-RS
Buttram, V. C. B., * 1

C

Campbell. G. D., 341-BR
Clark, J. E„ *257
Colbert, W. T„ *188, *502-RS
Conley, L. M., *600-RS

D

Davis, David. *101
Dill, A. R., 613-RB

E

Emerson. D. N., *321

F

Field, R. J., Jr., 659-BR

G

Gibson, N. P., 659-BR
Gibson, J. Y., *253
Goldberg, M. F., *149
Guernsey, C. E., *595

H

Haerer, A. F., *533
Hardy, J. D., *101
Hatten, K. W., *106, 613-BR
Hickman, B. T., *253
Hume, A. S., *636, *639

J

Jackson, J. F., 35-BR, *365

K

Keller. W. K., *110
Kennedy, R. B., 23-E, 25-E, 26-E,
27-E. 69-E. 71-E, 72-E, 73-E,
118-E, 119-E, 120-E, 191-E,

193-E. 273-E, 275-E. 276-E,

277-E. 335-E. 336-E, 337-E. 387-
E, 389-E, 390-E, 392-E, 394-E,
443-E, 445-E, 446-E, 447-E, 507-
E. 509-E, 510-E. 511-E, 512-E,
517-BR, 557-E. 559-E, 561-E.

565-E. 603-E, 605-E, 606-E, 607-
E. 647-E, 650-E, 651-E, 652-E

L

Lehan. P. H.. *101
Levi, S., *554-RS

M

McCay. T. S., *66-RS, *424-RS.
*644-RS

McKell, W. M., Jr., *477
McKinley, R. L.. Jr., 403-BR

Milam, J. T., *61

Miller, R. C., *585

Mora, Lidio O., 77-BR, *477

N

Nassar, G. J., *541
Nettles, D. C., *57
Nicholas, P. Y„ *257

P

Pullen, J., *543

R

Reid, L. R., *485
Ricks, H. C., 76-L
Rogers, J. B., 341-BR
Rosenblatt, W. H., *57
Royals, J. L., 22-PP, 68-PP. 116
PP, 190-PP, 272-PP, *374
Rush, H. L.. 35-BR

S

Schiesari, L., 262-CPC
Shaw, G. B., *13
Shell. B. J., *257
Sherline, D. M., *413
Smith. R. E., *417
Smith, R., *543

T

Thompson, W. B., 199-BR
Timmis. H. H., *101
Tipton. A. C.. Jr., *533
Tyler, H. B., 517-BR

W

Warren, R.. *581
Wilson, G. M., 573-BR
Wilson. W. B„ *53
Wriaht. D. I., *493

TABLE OF PAGES

January

1

to

52

July

365

to

412

December

629

to

674

February

53

to

100

August

413

to

476

By-Laws of the

March

101

to

148

September

477

to

532

Association

378

to

385

April

149

to

252

October

533

to

580

Transactions of the

May

253

to

308

November

581

to

628

House of Delegates .

427

to

473

June

309

to

364

DECEMBER 1970

671

MPAC

AMPAC

give you IMPACT, doctor!

But make it a mutual impact, doctor, because your PAC
needs you and you need your PAC. Both AMPAC and
each of the 50 state PAC’s are voluntary, nonprofit, un-
incorporated, autonomous groups whose members are
physicians, their wives, and others in allied professions.
Every group is bipartisan, bound by no party label. The
voting record, platform, and program of a candidate —
not his party — is what the PAC considers.

The basic purpose is twofold: To educate in political
affairs and to provide a means through which the physi-
cian-citizen can effectively make his voice heard in the po-
litical arena. MPAC is medically oriented and medically
directed by a 10 member board consisting of nine physi-
cians and a Woman’s Auxiliary representative.

With the elections behind, MPAC is looking ahead to
1971 when there will be a job to do. Make your voice
count by sending your dues today, $10 for MPAC and
$10 for AMPAC. Better send dues for your wife, too.

MISSISSIPPI MEDICAL
POLITICAL ACTION
COMMITTEE

672

JOURNAL MSMA

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Index to Advertisers

American Cancer Society ...... 10B

Arch Laboratories .673

Blue Cross Blue Shield 8

Campbell Soup Company 644A

Hill Crest Hospital 6

History of Medicine Limited 14

Hynson. Westcott and Dunning, Inc 3

Kay Surgical, Inc 673

Lederle Laboratories 4, 7

Leonard Wright Sanatorium 11

Eli Lilly and Company front cover, 18

Medicenters of America, Inc second cover

MPAC, AMPAC 672

New Orleans Graduate Medical Assembly 12

Pharmaceutical Manufacturers Association 660A

William P. Poythress and Co., Inc 652A, 652B

A. H. Robins Company 10, 10 A, 14A, 14B, 15

Roche Laboratories . . . . 660B, 660C, 660D, fourth cover

Schering Corporation 16, 17

G. D. Searle Company 644B, 644C

Smith Kline and French Laboratories 644D

Stuart Pharmaceuticals 634, 635

Thomas Yates and Company third cover

DECEMBER 1970

673

The Chamber of Commerce of the United States, the most influential
and powerful, broad-representation business organization in nation,
has denounced the Kennedy-Reuther-Woodcock national health insuranc
bill. Chamber points out that annual costs of fantastic and unreal
istic program, estimated at $77 billion a year, would be $1,000 pei
American family. A blue ribbon task force of 15 top business and
industry leaders is studying health delivery system for Chamber.

A special exhibit on man’s use of drugs will be presented by the
Smiths onian Institution in 1971. Pharmaceutical Manufacturers As-
sociation is coordinating drug makers* contributions which will sho
progress in pharmacology, benefits of proper use under medical man-
agement, and abuses no w prevalent. Exhibit will open next March
and continue until September. Smithsonian and PMA officials say
that 2 million Americans will view the major presentation.

A study of fees for five inpatient procedures for Medicare benefi-
ciaries shows that charges to this age-sensitive group have not
risen as rapidly as physicians' fees for all services. Procedures
studied are choleys tectomy, reduction of fracture of neck of the
femur, and prostatectomy and medical care of OVA and myocardial in-
farction. National Association of Blue Shield Plans says study
supports fact that physicians have not abused Medicare.

New trend to regulate hospital charges is looming on medical hori-
zon. New York legislature recently gave Commissioner of Health the
authority to fix hospital charge rates. California will consider
legislation next year to create state regulatory agency which would
exercise control over hospital charges. One aspect of new program
would be requirement of uniform hospital accounting procedures and
public reports on hospital finances.

Dental care insurance is growing and gaining favor, but built-in
problems remain to be solved. Last year, 2.9 million Americans had
some form of dental care insurance which paid out $78 million in
benefits. Most plans have healthy deductible of $20 to $50 per
course of care and co-pay requirement up to 25 per cent. Biggest
problem is nonacute aspects of dental conditions and postponability
of care, invariably making conditions worse and care costs higher.

health sciences library
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